Provider Demographics
NPI:1326227216
Name:BAYSIDE INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:BAYSIDE INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PRASHANT
Authorized Official - Middle Name:REHIT
Authorized Official - Last Name:SHUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-297-9500
Mailing Address - Street 1:998 HOSPITALITY WAY, SUITE 102
Mailing Address - Street 2:BAYSIDE INTERNAL MEDICINE, LLC
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-1757
Mailing Address - Country:US
Mailing Address - Phone:410-297-9500
Mailing Address - Fax:410-297-9016
Practice Address - Street 1:998 HOSPITALITY WAY, SUITE 102
Practice Address - Street 2:BAYSIDE INTERNAL MEDICINE, LLC
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21001-1757
Practice Address - Country:US
Practice Address - Phone:410-297-9500
Practice Address - Fax:410-297-9016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKEB4BAOtherCAREFIRST
MD489MOtherMEDICARE
MDNO GROUP #OtherMEDICAL ASSISTANCE OF MD
GADG3049OtherRAILROAD MEDICARE
DCG738OtherCAREFIRST