Basic Information
| Provider Information | |||||||||
| NPI: | 1124788146 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAPTIST AGEWELL PHYSICIANS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3162 | ||||||||
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| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841103162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042021032 | ||||||||
| FaxNumber: | 9043764107 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 3RD ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322665082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042024243 | ||||||||
| FaxNumber: | 9042024639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2021 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | BLACKMER | ||||||||
| AuthorizedOfficialFirstName: | GAYLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9042024104 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 207QG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No ID Information.