Basic Information
| Provider Information | |||||||||
| NPI: | 1215605688 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROOKSVILLE HMA PHYSICIAN MANAGEMENT LLC | ||||||||
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| OtherOrganizationName: | BAYFRONT HEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657211 | ||||||||
| FaxNumber: | 6156286877 | ||||||||
| Practice Location | |||||||||
| Address1: | 8425 NORTHCLIFFE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346061107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526062722 | ||||||||
| FaxNumber: | 6526062723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2021 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR DIR PROV ENROLLMENT & ONBOARDING | ||||||||
| AuthorizedOfficialTelephone: | 6154653334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VF0040X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery | 207X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 208600000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 261QR0206X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | FL | MEDICAID |