Blaine Payne, Inc
Organization Active NPI Geriatric Medicine (Family Medicine) Physician · Madison, FL
NPI 1770943409 · NPPES record last updated Jun 30, 2016
Key facts
- NPI
- 1770943409
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Geriatric Medicine (Family Medicine) Physician 207QG0300X
- License
- OS9255 (FL)
- Legal business name
- BLAINE PAYNE, INC
- Practice address
- 180 NW Haynes St
Madison, FL 32340-2010 - Phone
- (850) 973-1215
- Fax
- (866) 923-4163
- NPI assigned
- Feb 23, 2016
- Organization subpart
- No
Authorized official
- Name
- Tammey Revels
- Title
- Business Manager
- Phone
- (850) 973-1215
Practitioners 1
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 10D2110117 | Blaine Payne Inc | Certificate of waiver | Mar 8, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in FL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20170202000766 | FL | Part B Supplier - Clinic/Group Practice | 5597048363 |
Receives reassigned benefits from 1 practitioner Practice locations: Madison, FL |
National Provider Directory
Locations
180 NW Haynes St
Madison, FL 32340
Phone (850) 973-1215
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Geriatric Medicine (Family Medicine) Physician |
207QG0300X | OS9255 | FL | Yes |
Addresses
Primary practice location
180 NW Haynes St
Madison, FL 32340-2010
Mailing address
PO Box 185
Madison, FL 32341-0185
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 37137 | Other | BCBS | |
| 272752800 | Medicaid | FL | |
| HUMANA | Other | HUMANA | |
| SXJQY | Other | BCBS |
Other providers in Madison, FL
- Carl D Bartholomew
- Emily Rose Battillo
- Amy Elizabeth Beach
- Bee Mindful Psychiatry & Wellness, PLLC
- Judy Gray Bentley
- Blended Logistics LLC
- Debra Cooks Boatman
- Christie Bradfield
- Cindy Brown
- Felica Brown
All providers in Madison, FL · Geriatric Medicine (Family Medicine) Physician in Florida
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 30, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.