Provider Demographics
NPI:1982688354
Name:BAYSHORE PODIATRY CENTER
Entity Type:Organization
Organization Name:BAYSHORE PODIATRY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:REPKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:813-877-6636
Mailing Address - Street 1:508 S HABANA AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4161
Mailing Address - Country:US
Mailing Address - Phone:813-877-6636
Mailing Address - Fax:813-877-6610
Practice Address - Street 1:508 S HABANA AVE STE 230
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4161
Practice Address - Country:US
Practice Address - Phone:813-877-6636
Practice Address - Fax:813-877-6610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP00001221213E00000X
FL213E00000X, 213ES0000X
261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041093400Medicaid
FL87680ZMedicare ID - Type Unspecified