Provider Demographics
NPI:1902008063
Name:BAY PODIATRY, L.L.C.
Entity Type:Organization
Organization Name:BAY PODIATRY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-621-8699
Mailing Address - Street 1:30723A EMBER LN
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORT
Mailing Address - State:AL
Mailing Address - Zip Code:36527-5105
Mailing Address - Country:US
Mailing Address - Phone:251-621-8699
Mailing Address - Fax:
Practice Address - Street 1:5253 HIGHWAY 90 W
Practice Address - Street 2:SUITE L
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36619-4228
Practice Address - Country:US
Practice Address - Phone:251-661-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL238261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4150380003Medicare NSC