Provider Demographics
NPI:1043407323
Name:BAY AREA INTERNAL MEDICINE AND GERIATRIC CARE PA
Entity Type:Organization
Organization Name:BAY AREA INTERNAL MEDICINE AND GERIATRIC CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-545-8887
Mailing Address - Street 1:7047 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-4002
Mailing Address - Country:US
Mailing Address - Phone:727-545-8887
Mailing Address - Fax:
Practice Address - Street 1:7047 66TH ST
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-4002
Practice Address - Country:US
Practice Address - Phone:727-545-8887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053333207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269324100Medicaid
FLCC1712OtherRAILROAD MEDICARE GROUP
33974Medicare PIN
FLCC1712OtherRAILROAD MEDICARE GROUP
FL33974AMedicare PIN
FL33974BMedicare PIN