Provider Demographics
NPI:1336322833
Name:BAYSIDE HEALTHCARE BRANDON INC
Entity Type:Organization
Organization Name:BAYSIDE HEALTHCARE BRANDON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOFRIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-654-6568
Mailing Address - Street 1:615 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5972
Mailing Address - Country:US
Mailing Address - Phone:813-654-1856
Mailing Address - Fax:813-681-7268
Practice Address - Street 1:615 VONDERBURG DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5972
Practice Address - Country:US
Practice Address - Phone:813-654-1856
Practice Address - Fax:813-681-7268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC6754261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC6754OtherSTATE LICENSE