Healthcare Provider Details

I. General information

NPI: 1720085004
Provider Name (Legal Business Name): ROBERT S BAIN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N BONITA AVE
PANAMA CITY FL
32401-3623
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-1511
  • Fax:
Mailing address:
  • Phone: 904-450-6014
  • Fax: 904-450-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number40125
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME104942
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: