MEDICARE: BAYSIDE PHYSICAL THERAPY, 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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1528518131
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSIDE PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	501 FAIRMOUNT AVE
Second Line	:	SUITE 302
City	:	TOWSON
State	:	MD
Zip	:	21286-5457
Country	:	US
Telephone Number	:	410-927-8768
Fax Number	:

Provider Business Practice Location Address
First Line	:	33195 LIGHTHOUSE RD
Second Line	:	STE 7
City	:	SELBYVILLE
State	:	DE
Zip	:	19975-4071
Country	:	US
Telephone Number	:	302-436-0902
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	HARRIS THOMPSON
Credential	:
Telephone Number	:	410-885-6371

Provider Enumeration Date	:	10/06/2016
Last Update Date	:	10/06/2016

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