Healthcare Provider Details

I. General information

NPI: 1831313709
Provider Name (Legal Business Name): MARYROSE PATRICIA BAUSCHKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 N RANDOLPH ST STE 2
CHAMPAIGN IL
61820-3976
US

IV. Provider business mailing address

206 N RANDOLPH ST STE 2
CHAMPAIGN IL
61820-3976
US

V. Phone/Fax

Practice location:
  • Phone: 833-351-8255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036149210
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number9324776-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDR.0063905
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: