Healthcare Provider Details

I. General information

NPI: 1902847510
Provider Name (Legal Business Name): LARRY J BAYLIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7736 ORTONVILLE RD STE. A
CLARKSTON MI
48348-4483
US

IV. Provider business mailing address

7736 ORTONVILLE RD STE. A
CLARKSTON MI
48348-4483
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-5885
  • Fax: 248-625-6794
Mailing address:
  • Phone: 248-625-5885
  • Fax: 248-625-6794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101010781
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: