Healthcare Provider Details

I. General information

NPI: 1255904413
Provider Name (Legal Business Name): BAYCARE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 1ST ST S STE 100A
WINTER HAVEN FL
33880-3904
US

IV. Provider business mailing address

2995 DREW ST FL 3
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 863-280-6080
  • Fax: 863-292-4148
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LYNDA GORKEN
Title or Position: VP, PFS
Credential:
Phone: 727-281-9202