Basic Information
| Provider Information | |||||||||
| NPI: | 1841477890 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAYFRONT PHYSICIAN SPECIALTY SERVICE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 701 SIXTH ST. S. | ||||||||
| Address2: | |||||||||
| City: | ST. PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278936283 | ||||||||
| FaxNumber: | 7278936914 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 SEVENTH ST S | ||||||||
| Address2: | SUTIE 450 | ||||||||
| City: | ST. PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278936283 | ||||||||
| FaxNumber: | 7278936914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 10/31/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICH | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7278936223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAYFRONT MEDICAL CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00181560 | 05 | FL | MEDICAID |