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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1710157102
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	:	1864 LIME ST
Second Line	:	SUITE 6
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-4795
Country	:	US
Telephone Number	:	904-261-4050
Fax Number	:	904-261-5499

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

Provider Enumeration Date	:	03/03/2008
Last Update Date	:	12/14/2018

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