Provider Demographics
NPI:1154648863
Name:BAYSIDE PODIATRY P.A.
Entity Type:Organization
Organization Name:BAYSIDE PODIATRY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:RYBKA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:207-829-6463
Mailing Address - Street 1:326 MAIN ST
Mailing Address - Street 2:PO BOX 125
Mailing Address - City:CUMBERLAND CENTER
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3904
Mailing Address - Country:US
Mailing Address - Phone:207-829-6463
Mailing Address - Fax:207-829-6513
Practice Address - Street 1:326 MAIN ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND CENTER
Practice Address - State:ME
Practice Address - Zip Code:04021-3904
Practice Address - Country:US
Practice Address - Phone:207-829-6463
Practice Address - Fax:207-829-6513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD233213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME212590000Medicaid
MEMM4095Medicare PIN
MEU28405Medicare UPIN