Provider Demographics
NPI:1871668947
Name:BAYSIDE EMPLOYEE HEALTH CENTER
Entity Type:Organization
Organization Name:BAYSIDE EMPLOYEE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSIATRIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-780-6631
Mailing Address - Street 1:323 MARGINAL WAY
Mailing Address - Street 2:PO BOX 697
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2543
Mailing Address - Country:US
Mailing Address - Phone:207-780-6631
Mailing Address - Fax:207-780-6320
Practice Address - Street 1:323 MARGINAL WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2543
Practice Address - Country:US
Practice Address - Phone:207-780-6631
Practice Address - Fax:207-780-6320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1249305S00000X
ME013905305S00000X
MEPA-042305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service