Provider Demographics
NPI:1548213440
Name:BAYSHORE MEDICAL GROUP PC
Entity Type:Organization
Organization Name:BAYSHORE MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:L
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-888-7353
Mailing Address - Street 1:156 RTE 9
Mailing Address - Street 2:MARLBORO PLAZA
Mailing Address - City:ENGLISHTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-8231
Mailing Address - Country:US
Mailing Address - Phone:732-972-0660
Mailing Address - Fax:
Practice Address - Street 1:146 RTE 9
Practice Address - Street 2:MARLBORO PLAZA
Practice Address - City:ENGLISHTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8249
Practice Address - Country:US
Practice Address - Phone:732-972-0660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ024654Medicare ID - Type Unspecified