MEDICARE: BAPTIST PRIMARY CARE 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	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1457791246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAPTIST PRIMARY CARE INC

Provider Business Mailing Address
First Line	:	PO BOX 45443
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84145-0443
Country	:	US
Telephone Number	:	904-202-1032
Fax Number	:	904-376-4107

Provider Business Practice Location Address
First Line	:	1747 BAPTIST CLAY RD
Second Line	:	SUITE 110
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-8501
Country	:	US
Telephone Number	:	904-520-6620
Fax Number	:	904-520-6610

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MARSHA DONALDSON
Credential	:
Telephone Number	:	904-376-3703

Provider Enumeration Date	:	06/26/2013
Last Update Date	:	12/14/2018

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