Basic Information
| Provider Information | |||||||||
| NPI: | 1164092102 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYCARE MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 DREW ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337593012 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1840 MEASE DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | SAFETY HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346956606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277346888 | ||||||||
| FaxNumber: | 7272664913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2021 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | GORKEN | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP,PFS | ||||||||
| AuthorizedOfficialTelephone: | 7272819202 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator |
No ID Information.