MEDICARE: BAYSHORE SURGERY CENTER, LTD

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	261QA1903X	Ambulatory Surgical Clinic/Center	007306	TX

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	:	1508829011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSHORE SURGERY CENTER, LTD

Provider Business Mailing Address
First Line	:	3333 BAYSHORE BLVD
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77504-1952
Country	:	US
Telephone Number	:	832-386-0320
Fax Number	:	832-386-0240

Provider Business Practice Location Address
First Line	:	3333 BAYSHORE BLVD
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77504-1952
Country	:	US
Telephone Number	:	832-386-0320
Fax Number	:	832-386-0240

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DON LIEDTKE
Credential	:
Telephone Number	:	615-344-5507

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	10/22/2007

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