Basic Information
| Provider Information | |||||||||
| NPI: | 1245497940 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGIONAL HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAYSIDE FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 CRANBERRY STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165071078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148775274 | ||||||||
| FaxNumber: | 8148775882 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 CRANBERRY STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165071078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148775274 | ||||||||
| FaxNumber: | 8148775882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2008 | ||||||||
| LastUpdateDate: | 08/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | GIBBONS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8148777591 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGIONAL HEALTH SERVICES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.