Basic Information
| Provider Information | |||||||||
| NPI: | 1689011710 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAPTIST UROLOGY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2421 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841102421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042021032 | ||||||||
| FaxNumber: | 9043764107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1348 S 18TH ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320344785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042619108 | ||||||||
| FaxNumber: | 9042619911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2013 | ||||||||
| LastUpdateDate: | 12/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | DONALDSON | ||||||||
| AuthorizedOfficialFirstName: | MASHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9043763707 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | DU3519 | 01 | FL | RAILROAD MEDICARE | OTHER |