Provider Demographics
NPI:1720085004
Name:BAIN, ROBERT S JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:BAIN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6014
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:615 N BONITA AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3623
Practice Address - Country:US
Practice Address - Phone:850-769-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY401252085R0202X
FLME1049422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001509500Medicaid
FL145SJOtherBCBS
KY64922370Medicaid
FLF08265Medicare UPIN
KYF08265Medicare UPIN
FLCD199ZMedicare PIN
KY64922370Medicaid
FLCD199YMedicare PIN
FLCD199XMedicare PIN
FLCD199Medicare PIN
KY00046003Medicare PIN