Healthcare Provider Details

I. General information

NPI: 1710509203
Provider Name (Legal Business Name): BAPTIST PRIMARY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851042 US HIGHWAY 17
YULEE FL
32097-2845
US

IV. Provider business mailing address

PO BOX 45443
SALT LAKE CITY UT
84145-0443
US

V. Phone/Fax

Practice location:
  • Phone: 904-225-3824
  • Fax: 904-390-7440
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARSHA DONALDSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 904-376-3703