Provider Demographics
NPI:1700068160
Name:BAYSIDE FAMILY PRACTICE,L.L.C.
Entity Type:Organization
Organization Name:BAYSIDE FAMILY PRACTICE,L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:HOLLYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-763-8999
Mailing Address - Street 1:538 CYNWOOD DR STE 2
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-3887
Mailing Address - Country:US
Mailing Address - Phone:410-763-8999
Mailing Address - Fax:410-763-6949
Practice Address - Street 1:538 CYNWOOD DR STE 2
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3887
Practice Address - Country:US
Practice Address - Phone:410-763-8999
Practice Address - Fax:410-763-6949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF76892Medicare UPIN
MD1700068160Medicare PIN