MEDICARE: BAYSIDE PSYCHIATRY INC

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	261QM0850X	Adult Mental Health Clinic/Center	ME84774	FL

General Provider Information

NPI Number	:	1497990212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSIDE PSYCHIATRY INC

Provider Business Mailing Address
First Line	:	2003 WILSON AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4532
Country	:	US
Telephone Number	:	850-481-0306
Fax Number	:

Provider Business Practice Location Address
First Line	:	2003 WILSON AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4532
Country	:	US
Telephone Number	:	850-481-0306
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROY W DEAL
Credential	:	MD
Telephone Number	:	850-481-0306

Provider Enumeration Date	:	12/08/2008
Last Update Date	:	12/08/2008

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