Provider Demographics
NPI:1689011710
Name:BAPTIST UROLOGY, INC.
Entity Type:Organization
Organization Name:BAPTIST UROLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DONALDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-376-3707
Mailing Address - Street 1:PO BOX 2421
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-2421
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:1348 S 18TH ST STE 210
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4785
Practice Address - Country:US
Practice Address - Phone:904-261-9108
Practice Address - Fax:904-261-9911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-30
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDU3519OtherRAILROAD MEDICARE
FLHM141AMedicare PIN