Basic Information
| Provider Information | |||||||||
| NPI: | 1083153365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAPTIST-SOUTHEAST GYNECOLOGIC ONCOLOGY ASSOCIATES INC | ||||||||
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| OtherOrganizationName: | BAPTIST MD ANDERSON CANCER PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45278 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322325278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042022092 | ||||||||
| FaxNumber: | 9043937603 | ||||||||
| Practice Location | |||||||||
| Address1: | 14540 OLD SAINT AUGUSTINE RD | ||||||||
| Address2: | SUITE 2593 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322587418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043893993 | ||||||||
| FaxNumber: | 9043893994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2017 | ||||||||
| LastUpdateDate: | 02/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | MENGEL | ||||||||
| AuthorizedOfficialFirstName: | LEEANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9042027300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | DU3570 | 01 | FL | RR MEDICARE | OTHER | 009942200 | 05 | FL | MEDICAID |