Provider Demographics
NPI:1750440988
Name:BLACK BAG MEDICAL INC
Entity type:Organization
Organization Name:BLACK BAG MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LAYNE
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-371-4051
Mailing Address - Street 1:4320 DEERWOOD LAKE PKWY
Mailing Address - Street 2:SUITE 101, PMB 321
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1177
Mailing Address - Country:US
Mailing Address - Phone:904-371-4051
Mailing Address - Fax:904-807-4839
Practice Address - Street 1:4320 DEERWOOD LAKE PKWY
Practice Address - Street 2:SUITE 101, PMB 321
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1177
Practice Address - Country:US
Practice Address - Phone:904-371-4051
Practice Address - Fax:904-807-4839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI00526Medicare UPIN