Provider Demographics
NPI:1790018315
Name:BAYSIDE FAMILY MEDICINE CHESTERFIELD PC
Entity Type:Organization
Organization Name:BAYSIDE FAMILY MEDICINE CHESTERFIELD PC
Other - Org Name:BAYSIDE FAMILY MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RHEAUME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-598-2900
Mailing Address - Street 1:31225 23 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-1848
Mailing Address - Country:US
Mailing Address - Phone:586-598-2900
Mailing Address - Fax:586-598-2905
Practice Address - Street 1:31225 23 MILE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-1848
Practice Address - Country:US
Practice Address - Phone:586-598-2900
Practice Address - Fax:586-598-2905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4619550Medicaid
MIF80065Medicare UPIN