Basic Information
Provider Information
NPI: 1225086887
EntityType: 2
ReplacementNPI:  
OrganizationName: BAY CLINIC INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: HILO FAMILY HEALTH CENTER
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 450 KILAUEA AVE
Address2: STE 105
City: HILO
State: HI
PostalCode: 967203089
CountryCode: US
TelephoneNumber: 8089614071
FaxNumber: 8089615678
Practice Location
Address1: 1178 KINOOLE ST
Address2:  
City: HILO
State: HI
PostalCode: 967207206
CountryCode: US
TelephoneNumber: 8089691427
FaxNumber: 8089615678
Other Information
ProviderEnumerationDate: 05/05/2006
LastUpdateDate: 01/06/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: SPENCER
AuthorizedOfficialFirstName: THESLA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CREDENTIALING COORDINATOR
AuthorizedOfficialTelephone: 8089614082
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 01/06/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363L00000X  N193200000X MULTI-SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 
1041C0700X  N193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersSocial WorkerClinical
133V00000X  N193200000X MULTI-SPECIALTY GROUPDietary & Nutritional Service ProvidersDietitian, Registered 
163W00000X  N193200000X MULTI-SPECIALTY GROUPNursing Service ProvidersRegistered Nurse 
207Q00000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 
207R00000X HIN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 
208000000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPediatrics 
208D00000X HIN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansGeneral Practice 
208D00000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansGeneral Practice 
363A00000X  N193200000X MULTI-SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 
261QF0400X HIY Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)

ID Information
IDTypeStateIssuerDescription
51862305HI MEDICAID


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