1184713919 NPI number — BAYSIDE ENDOSCOPY CENTER, LLC

Table of content: (NPI 1184713919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184713919 NPI number — BAYSIDE ENDOSCOPY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYSIDE ENDOSCOPY CENTER, LLC
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:
OCEAN STATE ENDOSCOPY CENTER
Provider Other Organization Name Type Code:
3
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:
1184713919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 SEVEN SPRINGS WAY STE 600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-5605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
148 W RIVER ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02904-2615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-274-1260
Provider Business Practice Location Address Fax Number:
401-453-0330
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BALDOCK
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
BOYD
Authorized Official Title or Position:
OFFICER AND AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-234-5954

Provider Taxonomy Codes

  • Taxonomy code: 261QE0800X , with the licence number:  FAS01015 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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