Healthcare Provider Details

I. General information

NPI: 1245502327
Provider Name (Legal Business Name): BAYSIDE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28490 2ND ST
DAPHNE AL
36526-7150
US

IV. Provider business mailing address

28490 2ND ST
DAPHNE AL
36526-7150
US

V. Phone/Fax

Practice location:
  • Phone: 251-300-2030
  • Fax:
Mailing address:
  • Phone: 251-300-2030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number00006735
License Number StateAL

VIII. Authorized Official

Name: RAYMOND D.A. PETERSON
Title or Position: OWNER
Credential: M.D.
Phone: 251-300-2033