Provider Demographics
NPI:1124159090
Name:BAPTIST OCCUPATIONAL HEALTH, INC.
Entity type:Organization
Organization Name:BAPTIST OCCUPATIONAL HEALTH, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:B
Authorized Official - Last Name:MALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-376-4275
Mailing Address - Street 1:3563 PHILLIPS HWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5663
Mailing Address - Country:US
Mailing Address - Phone:904-202-5304
Mailing Address - Fax:904-202-5587
Practice Address - Street 1:1021 CESERY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5609
Practice Address - Country:US
Practice Address - Phone:904-743-2466
Practice Address - Fax:904-743-4070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3066Medicare PIN
4605870003Medicare NSC