Healthcare Provider Details

I. General information

NPI: 1790747673
Provider Name (Legal Business Name): BRUCE ALLEN KAUP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N GREENE ST BALTIMORE VAMC (MHCC/116A)
BALTIMORE MD
21201-1524
US

IV. Provider business mailing address

10 N GREENE ST BALTIMORE VAMC (MHCC/116A)
BALTIMORE MD
21201-1524
US

V. Phone/Fax

Practice location:
  • Phone: 410-605-7361
  • Fax:
Mailing address:
  • Phone: 410-605-7361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD30179
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberD30179
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: