MEDICARE: BLACK BAG MEDICAL 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	:	1750440988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK BAG MEDICAL INC

Provider Business Mailing Address
First Line	:	4320 DEERWOOD LAKE PKWY
Second Line	:	SUITE 101, PMB 321
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-1177
Country	:	US
Telephone Number	:	904-371-4051
Fax Number	:	904-807-4839

Provider Business Practice Location Address
First Line	:	4320 DEERWOOD LAKE PKWY
Second Line	:	SUITE 101, PMB 321
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-1177
Country	:	US
Telephone Number	:	904-371-4051
Fax Number	:	904-807-4839

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRIAN LAYNE STEPHENS
Credential	:	MD
Telephone Number	:	904-371-4051

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	08/22/2020

Similar Medicare Providers

1700825767 — PUBLIX SUPER MARKETS INC
Practice Location Address:

4320 DEERWOOD LAKE PKWY
JACKSONVILLE, FL
32216-1177

Practice Phone: 904-620-8344
Practice Fax: 904-997-0575

1275648255 — DR. SONAL G GOSWAMI MD
Practice Location Address:

4320 DEERWOOD LAKE PKWY STE 101-232
JACKSONVILLE, FL
32216-1177

Practice Phone: 904-513-8747
Practice Fax:

1174707236 — MS. YULANDA T FAISON- OYEBANJI DNP, NP
Practice Location Address:

4320 DEERWOOD LAKE PKWY , 310
JACKSONVILLE, FL
32216-1177

Practice Phone: 904-608-2900
Practice Fax:

1376845933 — DR. JAIME VICTORIA MARRA PH.D.
Practice Location Address:

4320 DEERWOOD LAKE PKWY STE 101-108
JACKSONVILLE, FL
32216-1177

Practice Phone: 904-479-5120
Practice Fax:

1528306909 — DR. JESSICA A PETERSON PHARMD
Practice Location Address:

4320 DEERWOOD LAKE PKWY
JACKSONVILLE, FL
32216-1177

Practice Phone: 904-620-0599
Practice Fax:

1396083580 — DR. CARLOS RAYMUNDO GOMEZ PHARMD
Practice Location Address:

4320 DEERWOOD LAKE PKWY
JACKSONVILLE, FL
32216-1177

Practice Phone: 904-620-8344
Practice Fax: 904-997-0575

Directions to “BLACK BAG MEDICAL INC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.