Provider Demographics
NPI:1710963236
Name:BAYFRONT ENTERPRISES INC
Entity Type:Organization
Organization Name:BAYFRONT ENTERPRISES INC
Other - Org Name:BAYFRONT CONVENIENT CARE CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WALDREP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-893-6707
Mailing Address - Street 1:7601 SEMINOLE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4859
Mailing Address - Country:US
Mailing Address - Phone:727-394-8442
Mailing Address - Fax:727-392-4249
Practice Address - Street 1:7000 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-5910
Practice Address - Country:US
Practice Address - Phone:727-526-3627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAYFRONT HEALTH SYSTEMS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-16
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98795Medicare ID - Type UnspecifiedGROUP NUMBER