1689011710 NPI number — BAPTIST UROLOGY, INC.

Table of content: (NPI 1689011710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689011710 NPI number — BAPTIST UROLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAPTIST UROLOGY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689011710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2421
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84110-2421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-202-1032
Provider Business Mailing Address Fax Number:
904-376-4107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1348 S 18TH ST STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FERNANDINA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32034-4785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-261-9108
Provider Business Practice Location Address Fax Number:
904-261-9911
Provider Enumeration Date:
05/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DONALDSON
Authorized Official First Name:
MASHA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
904-376-3707

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DU3519 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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