1104269109 NPI number — MICHAEL BAUM MA, ATC, PES

Table of content: MICHAEL BAUM MA, ATC, PES (NPI 1104269109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104269109 NPI number — MICHAEL BAUM MA, ATC, PES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAUM
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, ATC, PES
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:
1104269109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
TCU SPORTS MEDICINE
Provider Second Line Business Mailing Address:
TCU BOX 297600
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76129-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
TCU SPORTS MEDICINE
Provider Second Line Business Practice Location Address:
TCU BOX 297600
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76129-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-257-6649
Provider Business Practice Location Address Fax Number:
817-257-7323
Provider Enumeration Date:
04/10/2013

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: 2255A2300X , with the licence number:  AT5688 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2255A2300X , with the licence number: 2306 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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