=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144783291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYSHORE HEALTH AND WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2019
-----------------------------------------------------
Last Update Date | 04/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2299 9TH AVE N STE 1A
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33713-6851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-298-6545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2299 9TH AVE N STE 1A
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33713-6851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-298-6545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RYAN BAKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-298-6545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------