MEDICARE: DONALD J BACCUS M.D.

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	207VG0400X	Gynecology Physician	21134	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538152962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD J BACCUS M.D.

Provider Business Mailing Address
First Line	:	17280 W NORTH AVE
Second Line	:	SUITE 200
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-4366
Country	:	US
Telephone Number	:	262-754-8000
Fax Number	:	262-754-8008

Provider Business Practice Location Address
First Line	:	17280 W NORTH AVE
Second Line	:	SUITE 200
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-4366
Country	:	US
Telephone Number	:	262-754-8000
Fax Number	:	262-754-8008

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

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	07/09/2007

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