=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770034563
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY GROUP HEALTHCARE NORTHWEST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2016
-----------------------------------------------------
Last Update Date | 10/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 138 S MAIN ST STE 303
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-4089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-551-1222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8569 DOUBLETREE DR N
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-9805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-551-1222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. MAXIM AZAROV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-551-1222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------