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General NPI Number Information
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NPI Number | 1144508375
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Entity Type | Organization
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Legal Business Name | BAPTIST PRIMARY CARE - INTERNAL MEDICAL GROUP INC
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Dates
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Enumeration Date | 07/21/2011
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Last Update Date | 07/21/2011
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Provider Practice Location Address
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Address Line | 820 PRUDENTIAL DR SUITE 314
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City | JACKSONVILLE
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State | FL
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Zip | 32207-8210
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Country | US
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Telephone | 904-396-2223
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Fax |
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Provider Business Mailing Address
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Address Line | 8614 BAYMEADOWS WAY SUITE 100
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City | JACKSONVILLE
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State | FL
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Zip | 32256-8234
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Country | US
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Telephone | 904-396-0450
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Fax |
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Authorized Official
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Title or Position | SR. VICE PRESIDENT
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Name | EARL B MALLY
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Credential |
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Telephone | 904-376-4275
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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