Provider Demographics
NPI:1629251129
Name:BAYSIDE FAMILY & SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:BAYSIDE FAMILY & SPORTS MEDICINE PC
Other - Org Name:BAYSIDE FAMILY & SPORTS MEDICINE PC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-439-5100
Mailing Address - Street 1:2325 SUMMIT PARK DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8774
Mailing Address - Country:US
Mailing Address - Phone:231-439-5100
Mailing Address - Fax:231-439-9292
Practice Address - Street 1:2325 SUMMIT PARK DR
Practice Address - Street 2:SUITE 3
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8774
Practice Address - Country:US
Practice Address - Phone:231-439-5100
Practice Address - Fax:231-439-9292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP27540001Medicare PIN