Healthcare Provider Details

I. General information

NPI: 1871053090
Provider Name (Legal Business Name): MATTHEW RYAN BAUCOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-5401
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-578-5880
  • Fax: 859-578-5881
Mailing address:
  • Phone: 859-344-5555
  • Fax: 859-344-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number61969
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: