Provider Demographics
NPI:1407179989
Name:PRINCIPLE MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PRINCIPLE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-776-4265
Mailing Address - Street 1:7000 COBBLE CRK
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8638
Mailing Address - Country:US
Mailing Address - Phone:850-776-4265
Mailing Address - Fax:
Practice Address - Street 1:7000 COBBLE CRK
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8638
Practice Address - Country:US
Practice Address - Phone:850-776-4265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265911500Medicaid
AL009913418Medicaid
AL59067672OtherBC/BS OF ALABAMA
FL62842OtherBCBS OF FLORIDA
FL62842OtherBCBS OF FLORIDA
FL265911500Medicaid