Provider Demographics
NPI:1619257755
Name:BAYSIDE URGENT CARE CENTER INC.
Entity Type:Organization
Organization Name:BAYSIDE URGENT CARE CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:PETERKIN
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-508-2225
Mailing Address - Street 1:10030 NEW PARKE RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-5414
Mailing Address - Country:US
Mailing Address - Phone:813-508-2225
Mailing Address - Fax:813-920-4999
Practice Address - Street 1:1001 S FORT HARRISON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3905
Practice Address - Country:US
Practice Address - Phone:813-508-2225
Practice Address - Fax:813-920-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-21
Last Update Date:2011-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBTR-0029514261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270183900Medicaid
FL270183900Medicaid