Healthcare Provider Details

I. General information

NPI: 1790704765
Provider Name (Legal Business Name): JACK BAUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 W SUNSET BLVD STE 202
LOS ANGELES CA
90069-3703
US

IV. Provider business mailing address

PO BOX 5486
ORANGE CA
92863-5486
US

V. Phone/Fax

Practice location:
  • Phone: 310-550-1951
  • Fax:
Mailing address:
  • Phone: 818-550-0900
  • Fax: 818-550-0900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA40264
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA40264
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: