Basic Information
| Provider Information | |||||||||
| NPI: | 1720085004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAIN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD STE 4015 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506014 | ||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 N BONITA AVE | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324013623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507691511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 40125 | KY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME104942 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 001509500 | 05 | FL | MEDICAID | 145SJ | 01 | FL | BCBS | OTHER | 64922370 | 05 | KY | MEDICAID |