1609888742 NPI number — JEREMY PAUL BAUER MD

Table of content: JEREMY PAUL BAUER MD (NPI 1609888742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609888742 NPI number — JEREMY PAUL BAUER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAUER
Provider First Name:
JEREMY
Provider Middle Name:
PAUL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609888742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8500
Provider Second Line Business Mailing Address:
LOCKBOX 7642
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19178-7642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-281-8115
Provider Business Mailing Address Fax Number:
813-281-8656

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3101 SW SAM JACKSON PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239-3009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-221-3424
Provider Business Practice Location Address Fax Number:
503-221-3490
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  MD155424 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500651796 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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