Basic Information
| Provider Information | |||||||||
| NPI: | 1669964722 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAPTIST CARDIOLOGY INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BAPTIST HEART SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43667 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322033667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047200599 | ||||||||
| FaxNumber: | 9043764036 | ||||||||
| Practice Location | |||||||||
| Address1: | 533 W TWINCOURT TRL STE 701&702 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320958884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9049406057 | ||||||||
| FaxNumber: | 9049407601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2018 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | MASTERS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINSTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9043910058 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.