Provider Demographics
NPI:1568694180
Name:BAY CARE MED CORP
Entity Type:Organization
Organization Name:BAY CARE MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JED
Authorized Official - Middle Name:A
Authorized Official - Last Name:GROOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-206-5349
Mailing Address - Street 1:16-540 KEAAU PAHOA RD
Mailing Address - Street 2:STE 2-177
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-8155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16-540 KEAAU PAHOA RD
Practice Address - Street 2:STE 2-177
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749-8155
Practice Address - Country:US
Practice Address - Phone:808-206-5349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD4251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty