Basic Information
Provider Information | |||||||||
NPI: | 1780914192 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PMC/BAYSIDE ACQUISITION, L.L.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1100 E CAMPBELL RD | ||||||||
Address2: | SUITE 220 | ||||||||
City: | RICHARDSON | ||||||||
State: | TX | ||||||||
PostalCode: | 750816708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9724791380 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4001 PRESTON AVE | ||||||||
Address2: | SUITE 175 | ||||||||
City: | PASADENA | ||||||||
State: | TX | ||||||||
PostalCode: | 775052069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2814876111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/06/2010 | ||||||||
LastUpdateDate: | 01/06/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KENNEDY | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | W. | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9724791380 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PATIENTS MEDICAL CENTER, LTD. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.