Healthcare Provider Details

I. General information

NPI: 1194252510
Provider Name (Legal Business Name): BAPTIST CARDIOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 05/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 DAN PROCTOR DR STE 3300
SAINT MARYS GA
31558-3894
US

IV. Provider business mailing address

PO BOX 43667
JACKSONVILLE FL
32203-3667
US

V. Phone/Fax

Practice location:
  • Phone: 904-224-5189
  • Fax:
Mailing address:
  • Phone: 904-224-5189
  • Fax: 904-725-1622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: MARK A MASTERS
Title or Position: ADMINISTRATOR
Credential: PHD
Phone: 904-425-4557