Healthcare Provider Details

I. General information

NPI: 1932216835
Provider Name (Legal Business Name): JOHN VINCENT BAUGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 MILITARY ST
PORT HURON MI
48060-5416
US

IV. Provider business mailing address

190 WORDSWORTH AVENUE
FERNDALE MI
48220
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-7050
  • Fax:
Mailing address:
  • Phone: 248-547-3235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4301044857
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: