Basic Information
| Provider Information | |||||||||
| NPI: | 1386697779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | JOAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 ATLANTIC BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322118768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048051300 | ||||||||
| FaxNumber: | 9048051456 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 BORTHWICK AVE | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038017128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034365110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 10497 | NH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0109255Y0NH09 | 01 | NH | BCBS PIN # | OTHER |