Provider Demographics
NPI:1912052309
Name:BAYSIDE PHYSICAL THERAPY, L.L.C.
Entity type:Organization
Organization Name:BAYSIDE PHYSICAL THERAPY, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOVIENE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:410-829-5647
Mailing Address - Street 1:33195 LIGHTHOUSE RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:SELBYVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19975-4071
Mailing Address - Country:US
Mailing Address - Phone:302-436-0901
Mailing Address - Fax:
Practice Address - Street 1:33195 LIGHTHOUSE RD
Practice Address - Street 2:SUITE 7
Practice Address - City:SELBYVILLE
Practice Address - State:DE
Practice Address - Zip Code:19975-4071
Practice Address - Country:US
Practice Address - Phone:302-436-0901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCK769OtherBLUECHOICE
DE1000037489Medicaid
MD180CBAOtherCAREFIRST
MD180CBAOtherCAREFIRST
DEG02075Medicare PIN