Provider Demographics
NPI:1124788146
Name:BAPTIST AGEWELL PHYSICIANS INC
Entity type:Organization
Organization Name:BAPTIST AGEWELL PHYSICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-202-4104
Mailing Address - Street 1:PO BOX 3162
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3162
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:700 3RD ST STE 102
Practice Address - Street 2:
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-5082
Practice Address - Country:US
Practice Address - Phone:904-202-4243
Practice Address - Fax:904-202-4639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty