Provider Demographics
NPI:1184951139
Name:BAYPORT MEDICAL GROUP PC
Entity type:Organization
Organization Name:BAYPORT MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELFINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-472-0600
Mailing Address - Street 1:10 S SNEDECOR AVE
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-2133
Mailing Address - Country:US
Mailing Address - Phone:631-472-0600
Mailing Address - Fax:631-472-0602
Practice Address - Street 1:10 S SNEDECOR AVE
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:NY
Practice Address - Zip Code:11705-2133
Practice Address - Country:US
Practice Address - Phone:631-472-0600
Practice Address - Fax:631-472-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196926207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01771315Medicaid
NY01771315Medicaid
NYG32214Medicare UPIN