Provider Demographics
NPI:1316011398
Name:BAY SHORE DERMATOLOGY, PC
Entity Type:Organization
Organization Name:BAY SHORE DERMATOLOGY, PC
Other - Org Name:BAY SHORE DERMATOLOGY & LASER SURGERY CENTER, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-928-4944
Mailing Address - Street 1:7550 ASSUNTA CT
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-3069
Mailing Address - Country:US
Mailing Address - Phone:251-928-4944
Mailing Address - Fax:251-928-2086
Practice Address - Street 1:7550 ASSUNTA CT
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-3069
Practice Address - Country:US
Practice Address - Phone:251-928-4944
Practice Address - Fax:251-928-2086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty