Basic Information
| Provider Information | |||||||||
| NPI: | 1659720837 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYCARE MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 DREW ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337593012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272819390 | ||||||||
| FaxNumber: | 8136352613 | ||||||||
| Practice Location | |||||||||
| Address1: | 2995 DREW ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337593012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272819390 | ||||||||
| FaxNumber: | 8136352613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2016 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | GORKEN | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, PFS | ||||||||
| AuthorizedOfficialTelephone: | 7272819390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAYCARE MEDICAL GROUP, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.