Healthcare Provider Details

I. General information

NPI: 1235124488
Provider Name (Legal Business Name): JOSEPH R BAUMGART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 KINGSBURY DR
DEKALB IL
60115-8283
US

IV. Provider business mailing address

374 KINGSBURY DR
DEKALB IL
60115-8283
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-8621
  • Fax: 815-758-5838
Mailing address:
  • Phone: 815-758-8621
  • Fax: 815-758-5838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036-066682
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: