1164788154 NPI number — BAYCARE BEHAVIORAL HEALTH INC.

Table of content: (NPI 1164788154)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164788154 NPI number — BAYCARE BEHAVIORAL HEALTH INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYCARE BEHAVIORAL HEALTH INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BARDMOOR OFFICE - PRIMARY CARE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164788154
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2995 DREW ST FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33759-3012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-281-9390
Provider Business Mailing Address Fax Number:
813-635-2613

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8787 BRYAN DAIRY RD
Provider Second Line Business Practice Location Address:
SUITE 275
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33777-1251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-457-5614
Provider Business Practice Location Address Fax Number:
813-635-2613
Provider Enumeration Date:
04/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GORKEN
Authorized Official First Name:
LYNDA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
727-281-9390

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PENDING , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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