1619257755 NPI number — BAYSIDE URGENT CARE CENTER INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619257755 NPI number — BAYSIDE URGENT CARE CENTER INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYSIDE URGENT CARE CENTER 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:
Provider Other Organization Name Type Code:
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:
1619257755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10030 NEW PARKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33626-5414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-508-2225
Provider Business Mailing Address Fax Number:
813-920-4999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 S FORT HARRISON AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33756-3905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-508-2225
Provider Business Practice Location Address Fax Number:
813-920-4999
Provider Enumeration Date:
08/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
PETERKIN
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
813-508-2225

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  BTR-0029514 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 270183900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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