=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952017832
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAPTIST SOUTH SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2023
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14540 OLD ST. AUGUSTINE ROAD MEDICAL OFFICE BLDG. 2
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32258-7418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-648-0100
-----------------------------------------------------
Fax | 904-618-2159
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14540 OLD ST. AUGUSTINE ROAD MEDICAL OFFICE BLDG. 2
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32258-7418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-648-0100
-----------------------------------------------------
Fax | 904-618-2159
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SVP, CLIN SVC LN & AMB BUS DEV
-----------------------------------------------------
Name | CATHERINE GRAHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-202-2230
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------