Provider Demographics
NPI:1043429053
Name:BAYSIDE FAMILY HEALTHCARE CLINIC
Entity type:Organization
Organization Name:BAYSIDE FAMILY HEALTHCARE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS EXECUTIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTA
Authorized Official - Middle Name:M
Authorized Official - Last Name:FIALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-441-5660
Mailing Address - Street 1:PO BOX 144640
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33114-4640
Mailing Address - Country:US
Mailing Address - Phone:786-441-5660
Mailing Address - Fax:786-441-5660
Practice Address - Street 1:8488 W. HILLSBOROUGH AVENUE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615
Practice Address - Country:US
Practice Address - Phone:813-889-9800
Practice Address - Fax:813-889-9566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85120261QP2300X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274541100Medicaid
FLK9071Medicare UPIN