Provider Demographics
NPI:1487072047
Name:BAYSHORE AREA PEDIATRIC CLINIC, PA
Entity type:Organization
Organization Name:BAYSHORE AREA PEDIATRIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:H
Authorized Official - Last Name:KIEFFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-830-2996
Mailing Address - Street 1:3325 PLAINVIEW ST
Mailing Address - Street 2:SUITE C-9
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504-1989
Mailing Address - Country:US
Mailing Address - Phone:713-830-2996
Mailing Address - Fax:713-830-2998
Practice Address - Street 1:3325 PLAINVIEW ST
Practice Address - Street 2:SUITE C-9
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-1989
Practice Address - Country:US
Practice Address - Phone:713-830-2996
Practice Address - Fax:713-830-2998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1505208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092239503Medicaid