Provider Demographics
NPI:1174512701
Name:BAYMEADOWS PRIMARY CARE, INC.
Entity type:Organization
Organization Name:BAYMEADOWS PRIMARY CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR/ CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:S.
Authorized Official - Middle Name:AWAIS
Authorized Official - Last Name:IMAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-636-5400
Mailing Address - Street 1:10058 BAYMEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7177
Mailing Address - Country:US
Mailing Address - Phone:904-636-5400
Mailing Address - Fax:904-928-0654
Practice Address - Street 1:10058 BAYMEADOWS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7177
Practice Address - Country:US
Practice Address - Phone:904-636-5400
Practice Address - Fax:904-928-0654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81517207R00000X
FLME71382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273849000Medicaid
FLK2754Medicare PIN