MEDICARE: BAPTIST SPECIALTY PHYSICIANS INC

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	2080P0202X	Pediatric Cardiology Physician

General Provider Information

NPI Number	:	1417521725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAPTIST SPECIALTY PHYSICIANS INC

Provider Business Mailing Address
First Line	:	PO BOX 44047
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32231-4047
Country	:	US
Telephone Number	:	904-376-4083
Fax Number	:	904-391-5075

Provider Business Practice Location Address
First Line	:	8705 PERIMETER PARK BLVD STE 8
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-6353
Country	:	US
Telephone Number	:	904-296-7771
Fax Number	:	904-296-7772

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	THABATA FORD
Credential	:
Telephone Number	:	904-391-5578

Provider Enumeration Date	:	05/20/2021
Last Update Date	:	05/20/2021

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