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General NPI Number Information
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NPI Number | 1245502327
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Entity Type | Organization
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Legal Business Name | BAYSIDE PEDIATRICS, LLC
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Dates
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Enumeration Date | 02/03/2012
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Last Update Date | 02/03/2012
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Provider Practice Location Address
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Address Line | 28490 2ND ST
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City | DAPHNE
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State | AL
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Zip | 36526-7150
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Country | US
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Telephone | 251-300-2030
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Fax |
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Provider Business Mailing Address
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Address Line | 28490 2ND ST
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City | DAPHNE
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State | AL
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Zip | 36526-7150
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Country | US
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Telephone | 251-300-2030
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RAYMOND D.A. PETERSON
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Credential | M.D.
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Telephone | 251-300-2033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 00006735
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License Number State | AL
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