Provider Demographics
NPI:1114477940
Name:BAPTIST ENT SPECIALISTS INC
Entity Type:Organization
Organization Name:BAPTIST ENT SPECIALISTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-202-5370
Mailing Address - Street 1:PO BOX 41516
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-1516
Mailing Address - Country:US
Mailing Address - Phone:904-202-5111
Mailing Address - Fax:904-391-5836
Practice Address - Street 1:1348 S 18TH ST
Practice Address - Street 2:SUITE 340
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4785
Practice Address - Country:US
Practice Address - Phone:904-775-5957
Practice Address - Fax:904-844-2149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDS0498OtherRR MEDICARE
FL004630400Medicaid
FLFE390BMedicare PIN