Provider Demographics
NPI:1417423377
Name:BAYCARE OUTPATIENT IMAGING LLC
Entity Type:Organization
Organization Name:BAYCARE OUTPATIENT IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, PFS
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GORKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-281-9065
Mailing Address - Street 1:2995 DREW STREET
Mailing Address - Street 2:EAST BLDG 2ND FLOOR
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759
Mailing Address - Country:US
Mailing Address - Phone:727-281-9390
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:2470 BLOOMINGDALE AVE STE 115
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-6403
Practice Address - Country:US
Practice Address - Phone:727-281-9479
Practice Address - Fax:813-586-8516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-18
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101818500Medicaid