BAYMEADOWS PRIMARY CARE, INC.

Contacts

Phone	+1 904-636-5400
Fax	9049280654

Authorized person

Name	MR. S. AWAIS IMAM
Role	PRACTICE ADMINISTRATOR/ CFO
Phone	9046365400

Taxonomy

Taxonomy Code	207Q00000X - Family Medicine Physician
License Number	ME71382
State	FL
Is Primary	Yes
Taxonomy Code	207R00000X - Internal Medicine Physician
License Number	ME81517
State	FL
Is Primary	No

Other Provider Identifiers

Issuer	MEDICAID
Number	273849000
State	FL

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2008-01-01
Business code	621111
Sponsor’s telephone number	9046365400
Plan sponsor’s address	10058 BAYMEADOWS ROAD, JACKSONVILLE, FL, 32256

Signature of

Role	Plan administrator
Date	2016-08-29
Name of individual signing	AWAIS IMAM
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2008-01-01
Business code	621111
Sponsor’s telephone number	9046365400
Plan sponsor’s address	10058 BAYMEADOWS ROAD, JACKSONVILLE, FL, 32256

Signature of

Role	Plan administrator
Date	2015-10-14
Name of individual signing	AWAIS IMAM
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2008-01-01
Business code	621111
Sponsor’s telephone number	9046365400
Plan sponsor’s address	10058 BAYMEADOWS ROAD, JACKSONVILLE, FL, 32256

Signature of

Role	Plan administrator
Date	2014-07-31
Name of individual signing	AWAIS IMAM
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2008-01-01
Business code	621111
Sponsor’s telephone number	9046365612
Plan sponsor’s address	10160 BISHOP LAKE RD W, JACKSONVILLE, FL, 32256

Signature of

Role	Plan administrator
Date	2013-10-15
Name of individual signing	BAYMEADOWS PRIMARY CARE INC
Valid signature	Filed with authorized/valid electronic signature