=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164536579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYSIDE UROLOGY MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2006
-----------------------------------------------------
Last Update Date | 05/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 4TH AVE STE 303
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-4429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-420-0201
-----------------------------------------------------
Fax | 619-425-7795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 4TH AVE STE 303
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-4429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-420-0201
-----------------------------------------------------
Fax | 619-425-7795
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL B. HUNTING
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 619-420-0201
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------