Healthcare Provider Details

I. General information

NPI: 1093834830
Provider Name (Legal Business Name): BAYSIDE PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 STEEPLE CHASE DR STE 103
PRINCE FREDERICK MD
20678-4049
US

IV. Provider business mailing address

301 STEEPLE CHASE DR STE 103
PRINCE FREDERICK MD
20678-4049
US

V. Phone/Fax

Practice location:
  • Phone: 410-414-5633
  • Fax: 410-414-5911
Mailing address:
  • Phone: 410-414-5633
  • Fax: 410-414-5911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR126934
License Number StateMD

VIII. Authorized Official

Name: MS. DEBORAH R BROWER
Title or Position: OWNER
Credential: CRNP
Phone: 410-414-5633