MEDICARE: BAYSPINE SURGERY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1013116748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSPINE SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	3065 RICHMOND PKWY STE 100
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94806-5719
Country	:	US
Telephone Number	:	510-243-2130
Fax Number	:

Provider Business Practice Location Address
First Line	:	3065 RICHMOND PKWY STE 100
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94806-5719
Country	:	US
Telephone Number	:	510-243-2130
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ROGER W. SHORTZ
Credential	:	M.D.
Telephone Number	:	510-243-2130

Provider Enumeration Date	:	07/12/2007
Last Update Date	:	07/12/2007

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