Provider Demographics
NPI:1881215994
Name:BAYSIDE PEDIATRICS-FULTON, LLC
Entity Type:Organization
Organization Name:BAYSIDE PEDIATRICS-FULTON, LLC
Other - Org Name:BAYSIDE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:410-224-3848
Mailing Address - Street 1:2024 WEST ST STE 400
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7625 MAPLE LAWN BLVD STE 145
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2565
Practice Address - Country:US
Practice Address - Phone:410-224-7667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOLD AND ESCOBOSA P A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-29
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1710054598Medicaid
MD1376029389Medicaid
MD1326096678Medicaid
MD1528104452Medicaid
MD1942725064Medicaid
MD1407992407Medicaid
MD1053488841Medicaid