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General NPI Number Information
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NPI Number | 1770943409
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Entity Type | Organization
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Legal Business Name | BLAINE PAYNE, INC
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Dates
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Enumeration Date | 02/23/2016
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Last Update Date | 06/30/2016
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Provider Practice Location Address
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Address Line | 180 NW HAYNES ST
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City | MADISON
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State | FL
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Zip | 32340-2010
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Country | US
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Telephone | 850-973-1215
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Fax | 866-923-4163
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Provider Business Mailing Address
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Address Line | PO BOX 185
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City | MADISON
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State | FL
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Zip | 32341-0185
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | TAMMEY REVELS
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Credential |
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Telephone | 850-973-1215
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | OS9255
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License Number State | FL
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