Provider Demographics
NPI:1720322811
Name:BAPTIST PHYSICIAN GROUP LLC
Entity Type:Organization
Organization Name:BAPTIST PHYSICIAN GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRYON
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:RAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-469-2319
Mailing Address - Street 1:PO BOX 30532
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1532
Mailing Address - Country:US
Mailing Address - Phone:850-478-1312
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:9400 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 309
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5752
Practice Address - Country:US
Practice Address - Phone:850-479-3320
Practice Address - Fax:850-479-8789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69848207X00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39662OtherFLORIDA BLUE
FL001330100Medicaid
AL110608Medicaid