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1407179989

NPI Code Detail

MEDICARE: PRINCIPLE MEDICAL GROUP, LLC

MEDICARE: PRINCIPLE MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	OS7158	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	59067672	OTHER	AL	BC/BS OF ALABAMA
4	62842	OTHER	FL	BCBS OF FLORIDA

General Provider Information

NPI Number	:	1407179989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCIPLE MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	7000 COBBLE CRK
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32504-8638
Country	:	US
Telephone Number	:	850-776-4265
Fax Number	:

Provider Business Practice Location Address
First Line	:	7000 COBBLE CRK
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32504-8638
Country	:	US
Telephone Number	:	850-776-4265
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROMAN S. BAUTISTA
Credential	:	D.O.
Telephone Number	:	850-776-4265

Provider Enumeration Date	:	03/11/2010
Last Update Date	:	02/13/2013

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Directions to “PRINCIPLE MEDICAL GROUP, LLC ” Practice Location

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