MEDICARE: ANDREW J BALDUS O.D.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2616	WI

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	410046660	OTHER	WI	RAILROAD MEDICARE-COLBY
6	410046659	OTHER	WI	RAILROAD MEDICARE-MEDFORD

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10445	OTHER	WI	NVA-MEDFORD
2	39-1967186	OTHER	WI	FEDERAL TAX ID-COLBY
4	39-1229699	OTHER	WI	FEDERAL TAX ID-MEDFORD
5	391967186019	OTHER	WI	BLUE CROSS BLUE SHIELD-CO
7	1271670001	OTHER	WI	DMERC-COLBY GROUP
8	2616	OTHER	WI	LICENSE
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	391229699015	OTHER	WI	BLUE CROSS BLUE SHIELD-ME
11	0474980001	OTHER	WI	DMERC-MEDFORD GROUP
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
13	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
14	74812	OTHER	WI	SECURITY HEALTH PLAN-COLB
15	74813	OTHER	WI	SECURITY HEALTH PLAN-MEDF

NPI Number	:	1316924590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW J BALDUS O.D.

Provider Business Mailing Address
First Line	:	1700 W PARADISE DR
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-9795
Country	:	US
Telephone Number	:	414-454-7734
Fax Number	:

Provider Business Practice Location Address
First Line	:	1700 W PARADISE DR
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-9795
Country	:	US
Telephone Number	:	414-454-7734
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	10/17/2023

2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNT 6 WEST , KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
ROCKVILLE, MD
20852-4908

Practice Phone: 301-816-6660
Practice Fax: 301-816-6308