Provider Demographics
NPI:1821647314
Name:BAYSIDE MEDICAL OF NORTHWEST FL LLC
Entity Type:Organization
Organization Name:BAYSIDE MEDICAL OF NORTHWEST FL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCCROAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-357-8192
Mailing Address - Street 1:204 CORAL DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-6257
Mailing Address - Country:US
Mailing Address - Phone:850-357-8192
Mailing Address - Fax:850-659-9565
Practice Address - Street 1:101 GOOD MORNING ST STE 109B
Practice Address - Street 2:
Practice Address - City:PORT SAINT JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-4765
Practice Address - Country:US
Practice Address - Phone:850-357-8192
Practice Address - Fax:850-659-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-06
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty