Provider Demographics
NPI:1093798704
Name:BAYSHORE PODIATRY CENTER INC
Entity Type:Organization
Organization Name:BAYSHORE PODIATRY CENTER INC
Other - Org Name:BAYSHORE PODIATRY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:REPKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:813-877-6636
Mailing Address - Street 1:508 S HABANA AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4181
Mailing Address - Country:US
Mailing Address - Phone:813-877-6636
Mailing Address - Fax:813-877-6610
Practice Address - Street 1:508 S HABANA AVE
Practice Address - Street 2:230
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4181
Practice Address - Country:US
Practice Address - Phone:813-877-6636
Practice Address - Fax:813-877-6636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP02913213E00000X
213ES0000X, 213ES0103X
FL213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029670800Medicaid
FL029670800Medicaid
FL77429Medicare PIN
FL0727650001Medicare NSC