Healthcare Provider Details

I. General information

NPI: 1194926626
Provider Name (Legal Business Name): ST JOHNS CARDIOVASCULAR PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK BLVD STE 1000
ST AUGUSTINE FL
32086-3707
US

IV. Provider business mailing address

PO BOX 348
ST AUGUSTINE FL
32085-0348
US

V. Phone/Fax

Practice location:
  • Phone: 904-810-1045
  • Fax: 904-810-1046
Mailing address:
  • Phone: 904-810-1045
  • Fax: 904-810-1046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME45744
License Number StateFL

VIII. Authorized Official

Name: DR. HOWARD A BAKER
Title or Position: PRESIDENT
Credential: MD
Phone: 904-810-1045