MEDICARE: BAYCARE OUTPATIENT IMAGING LLC

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	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164006359
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYCARE OUTPATIENT IMAGING LLC

Provider Business Mailing Address
First Line	:	2995 DREW ST FL 2
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33759-3012
Country	:	US
Telephone Number	:	727-281-9065
Fax Number	:

Provider Business Practice Location Address
First Line	:	18600 FERNVIEW ST STE 101
Second Line	:
City	:	LAND O LAKES
State	:	FL
Zip	:	34638-6212
Country	:	US
Telephone Number	:	727-281-9065
Fax Number	:

Authorized Official
Title or Position	:	VP PATIENT FINANCIAL SERVICES
Name	:	LYNDA GORKEN
Credential	:
Telephone Number	:	727-281-9202

Provider Enumeration Date	:	05/12/2021
Last Update Date	:	07/11/2024

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