Provider Demographics
NPI:1689633240
Name:BAYSIDE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:BAYSIDE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BUDD
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:SHENKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-587-2505
Mailing Address - Street 1:11875 DUBLIN BLVD
Mailing Address - Street 2:SUITE C140
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-2843
Mailing Address - Country:US
Mailing Address - Phone:925-587-2505
Mailing Address - Fax:925-587-2511
Practice Address - Street 1:5720 STONERIDGE MALL RD
Practice Address - Street 2:SUITE 240
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-2828
Practice Address - Country:US
Practice Address - Phone:925-463-1234
Practice Address - Fax:925-463-9599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06346ZOtherMEDICARE
CAZZZ06346ZMedicare PIN