Provider Demographics
NPI:1740345057
Name:BAYSIDE PODIATRY PA
Entity type:Organization
Organization Name:BAYSIDE PODIATRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORRI
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:605-641-5794
Mailing Address - Street 1:PO BOX 422
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-0422
Mailing Address - Country:US
Mailing Address - Phone:605-641-5794
Mailing Address - Fax:480-393-5577
Practice Address - Street 1:927 E COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-2783
Practice Address - Country:US
Practice Address - Phone:605-641-5794
Practice Address - Fax:480-393-5577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3166213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5320260001OtherDMERC
FLP00205681OtherMEDICARE RAILROAD
FL65859ZOtherBLUE CROSS
FLK6349Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
FLP00205681OtherMEDICARE RAILROAD