Provider Demographics
NPI:1093110017
Name:BAYSHORE PAIN MANAGEMENT LLC
Entity Type:Organization
Organization Name:BAYSHORE PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-264-8900
Mailing Address - Street 1:250 MAPLE PL
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-1144
Mailing Address - Country:US
Mailing Address - Phone:732-264-8900
Mailing Address - Fax:
Practice Address - Street 1:250 MAPLE PL
Practice Address - Street 2:
Practice Address - City:KEYPORT
Practice Address - State:NJ
Practice Address - Zip Code:07735-1144
Practice Address - Country:US
Practice Address - Phone:732-264-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty