Provider Demographics
NPI:1114236940
Name:BAY SIDE MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:BAY SIDE MEDICAL CENTER LLC
Other - Org Name:LEO B. DALTON, D.O.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-393-8715
Mailing Address - Street 1:9545 BAY PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33708-3754
Mailing Address - Country:US
Mailing Address - Phone:727-393-8715
Mailing Address - Fax:727-393-8717
Practice Address - Street 1:9545 BAY PINES BLVD
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33708-3754
Practice Address - Country:US
Practice Address - Phone:727-393-8715
Practice Address - Fax:727-393-8717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS3212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS3212OtherSTATE LICENSE NUMBER
FL040070000Medicaid
FL040070000Medicaid
FL81796Medicare PIN