Basic Information
| Provider Information | |||||||||
| NPI: | 1235898529 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYCARE OUTPATIENT IMAGING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 DREW ST FL 2 | ||||||||
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| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337593012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272819065 | ||||||||
| FaxNumber: | 8136352613 | ||||||||
| Practice Location | |||||||||
| Address1: | 4503 BRUCE B. DOWNS BLVLD. | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WESLEY CHAPEL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135868500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2021 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | GORKEN | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7272819202 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | FL | MEDICAID | PENDING | 01 | FL | MEDICARE | OTHER |