Healthcare Provider Details

I. General information

NPI: 1174808992
Provider Name (Legal Business Name): BAY STREET ORTHOPAEDICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4048 CEDAR BLUFF DR SUITE 1
PETOSKEY MI
49770-8895
US

IV. Provider business mailing address

4048 CEDAR BLUFF DR SUITE 1
PETOSKEY MI
49770-8895
US

V. Phone/Fax

Practice location:
  • Phone: 231-347-5155
  • Fax: 231-347-6128
Mailing address:
  • Phone: 231-347-5155
  • Fax: 231-347-6128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MARK R MCMURRAY
Title or Position: DIRECT OWNER
Credential: MD
Phone: 231-347-5155