| Name: | Bayside Pediatrics, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Dissolved |
| Date of registration: | 21 Oct 2011 (13 years ago) |
| Date of dissolution: | 30 Dec 2014 |
| Entity Number: | 000-028-100 |
| Register Number: | 000028100 |
| County: | Baldwin |
| Place of Formation: | Baldwin County |
| Registered Office Street Address: | 4 GREENBRIER LANEFAIRHOPE, AL 36532 |
| Registered Office Street Address ZIP Code: | 36532 |
Activities
TO ENGAGE IN ANY LAWFUL ACT
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1245502327 | 2012-02-03 | 2012-02-03 | 28490 2ND ST, DAPHNE, AL, 365267150, US | 28490 2ND ST, DAPHNE, AL, 365267150, US | |||||||||||||||||||||||
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| Phone | +1 251-300-2030 |
Authorized person
| Name | RAYMOND D.A. PETERSON |
| Role | OWNER |
| Phone | 2513002033 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| License Number | 00006735 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 529926260 |
| State | AL |
| Name | Role |
|---|---|
| PETERSON, INGRID B | Agent |
Date of last update: 30 Jul 2024
Sources: Alabama Secretary of State
