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General NPI Number Information
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NPI Number | 1619257755
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Entity Type | Organization
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Legal Business Name | BAYSIDE URGENT CARE CENTER INC.
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Dates
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Enumeration Date | 08/21/2011
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Last Update Date | 08/21/2011
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Provider Practice Location Address
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Address Line | 1001 S FORT HARRISON AVE SUITE 101
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City | CLEARWATER
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State | FL
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Zip | 33756-3905
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Country | US
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Telephone | 813-508-2225
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Fax | 813-920-4999
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Provider Business Mailing Address
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Address Line | 10030 NEW PARKE RD
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City | TAMPA
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State | FL
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Zip | 33626-5414
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Country | US
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Telephone | 813-508-2225
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Fax | 813-920-4999
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DR. RICHARD PETERKIN WALLACE
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Credential | MD
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Telephone | 813-508-2225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | BTR-0029514
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License Number State | FL
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