Basic Information
Provider Information | |||||||||
NPI: | 1073147849 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAYCARE URGENT CARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2995 DREW ST FL 2 | ||||||||
Address2: |   | ||||||||
City: | CLEARWATER | ||||||||
State: | FL | ||||||||
PostalCode: | 337593012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7272819390 | ||||||||
FaxNumber: | 8136352613 | ||||||||
Practice Location | |||||||||
Address1: | 2645 S FLORIDA AVE | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338033829 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636066880 | ||||||||
FaxNumber: | 8632297592 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2020 | ||||||||
LastUpdateDate: | 03/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GORKEN | ||||||||
AuthorizedOfficialFirstName: | LYNDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP, PFS | ||||||||
AuthorizedOfficialTelephone: | 7272819390 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X |   |   | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 274807000 | 05 | FL |   | MEDICAID |