Provider Demographics
NPI:1467886267
Name:BASS LAKE INPATIENT SERVICES, LLC
Entity Type:Organization
Organization Name:BASS LAKE INPATIENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & PRESIDENT , INPATIENT SVCS
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BYRNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-444-7009
Mailing Address - Street 1:PO BOX 37944
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-0544
Mailing Address - Country:US
Mailing Address - Phone:800-444-7009
Mailing Address - Fax:800-305-3233
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-862-0213
Practice Address - Fax:800-305-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty