MEDICARE: BAYSHORE CHIROPRACTIC, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	X009043	NY

General Provider Information

NPI Number	:	1023335619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSHORE CHIROPRACTIC, P.C.

Provider Business Mailing Address
First Line	:	PO BOX 315
Second Line	:
City	:	BALDWIN
State	:	NY
Zip	:	11510-0315
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1421 SHEEPSHEAD BAY RD
Second Line	:	# 594
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3813
Country	:	US
Telephone Number	:	718-421-1705
Fax Number	:	516-378-8088

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT SUPER
Credential	:	DC
Telephone Number	:	917-449-7582

Provider Enumeration Date	:	04/23/2010
Last Update Date	:	04/23/2010

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