Provider Demographics
NPI:1164411419
Name:BAISE, G RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:G
Middle Name:RICHARD
Last Name:BAISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2901
Mailing Address - Country:US
Mailing Address - Phone:941-957-4987
Mailing Address - Fax:941-955-7905
Practice Address - Street 1:1428 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2901
Practice Address - Country:US
Practice Address - Phone:941-957-4987
Practice Address - Fax:941-955-7905
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0017737174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL58207Medicare ID - Type Unspecified
FLD86084Medicare UPIN