Basic Information
| Provider Information | |||||||||
| NPI: | 1891468096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYCARE MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 DREW ST FL 3 | ||||||||
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| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337593012 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4321 N MACDILL AVE STE 407 | ||||||||
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| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135548690 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2021 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | GORKEN | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, PFS | ||||||||
| AuthorizedOfficialTelephone: | 7272812021 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207T00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.