Healthcare Provider Details

I. General information

NPI: 1851488720
Provider Name (Legal Business Name): MATTHEW JOSEPH BAUCOM RPSGT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11649 N PORT WASHINGTON RD STE 109
MEQUON WI
53092
US

IV. Provider business mailing address

1580 W PORTVIEW DR APT #2
PORT WASHINGTON WI
53074
US

V. Phone/Fax

Practice location:
  • Phone: 262-241-8022
  • Fax: 262-241-8047
Mailing address:
  • Phone: 262-894-6833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: