=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790738847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYSHORE PHYSICIANS PROFFESSIONAL ASSOCIATES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 10/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 180 KINGS HWY
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07748-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-671-0557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 180 KINGS HWY
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07748-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. L. SCOTT LARSEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 732-888-7353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------