Healthcare Provider Details

I. General information

NPI: 1760168330
Provider Name (Legal Business Name): BAYSIDE MEDICAL PRACTICE OF VILANO BEACH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 09/01/2025
Certification Date: 09/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 YACHT CLUB DR
ST AUGUSTINE FL
32084-2196
US

IV. Provider business mailing address

240 SAN MARCO AVE
SAINT AUGUSTINE FL
32084-2729
US

V. Phone/Fax

Practice location:
  • Phone: 904-217-4550
  • Fax: 904-907-2113
Mailing address:
  • Phone: 904-217-4550
  • Fax: 904-907-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMMY ROWLAND DYE
Title or Position: PRESIDENT
Credential: APN
Phone: 305-916-0183