Basic Information
| Provider Information | |||||||||
| NPI: | 1609392018 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAPTIST PHYSICIAN GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30532 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325031532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504781312 | ||||||||
| FaxNumber: | 8504749060 | ||||||||
| Practice Location | |||||||||
| Address1: | 9400 UNIVERSITY PKWY STE 101A | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325145485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509163700 | ||||||||
| FaxNumber: | 8509163710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2017 | ||||||||
| LastUpdateDate: | 08/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | RAYNES | ||||||||
| AuthorizedOfficialFirstName: | BRYON | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8504692319 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207RS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 39662 | 01 | FL | FLORIDA BLUE | OTHER | 001330100 | 05 | FL | MEDICAID |