MEDICARE: TEOFILO S. BAUTISTA, M.D., P.C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	01032450A	IN

General Provider Information

NPI Number	:	1215110200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEOFILO S. BAUTISTA, M.D., P.C

Provider Business Mailing Address
First Line	:	642 S LAKE ST
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46403-2967
Country	:	US
Telephone Number	:	219-938-4481
Fax Number	:	219-938-6480

Provider Business Practice Location Address
First Line	:	642 S LAKE ST
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46403-2967
Country	:	US
Telephone Number	:	219-938-4481
Fax Number	:	219-938-6480

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TEOFILO BAUTISTA
Credential	:	M.D.
Telephone Number	:	219-938-4481

Provider Enumeration Date	:	12/12/2007
Last Update Date	:	12/12/2007

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