=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912716135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAPTIST CARDIOLOGY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2025
-----------------------------------------------------
Last Update Date | 01/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10601 SAN JOSE BLVD STE 1402
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-8232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-425-4566
-----------------------------------------------------
Fax | 904-858-3289
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 746652
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-6652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-202-2092
-----------------------------------------------------
Fax | 904-376-4075
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | TYRONE STEWART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-425-4625
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------