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General NPI Number Information
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NPI Number | 1093834830
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Entity Type | Organization
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Legal Business Name | BAYSIDE PRIMARY CARE LLC
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 05/27/2014
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Provider Practice Location Address
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Address Line | 301 STEEPLE CHASE DR STE 103
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City | PRINCE FREDERICK
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State | MD
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Zip | 20678-4049
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Country | US
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Telephone | 410-414-5633
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Fax | 410-414-5911
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Provider Business Mailing Address
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Address Line | 301 STEEPLE CHASE DR STE 103
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City | PRINCE FREDERICK
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State | MD
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Zip | 20678-4049
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Country | US
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Telephone | 410-414-5633
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Fax | 410-414-5911
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Authorized Official
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Title or Position | OWNER
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Name | MS. DEBORAH R BROWER
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Credential | CRNP
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Telephone | 410-414-5633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | R126934
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License Number State | MD
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