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General NPI Number Information
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NPI Number | 1396051561
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Entity Type | Individual
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Provider Name | BENJAMIN GENESIS M BAUTISTA II MD
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Gender | Male
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Dates
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Enumeration Date | 08/26/2010
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Last Update Date | 07/10/2017
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Provider Practice Location Address
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Address Line | 855 N WESTHAVEN DR
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City | OSHKOSH
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State | WI
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Zip | 54904-7668
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Country | US
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Telephone | 920-456-7400
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Fax |
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Provider Business Mailing Address
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Address Line | 2100 S. MARSHALL BLVD., APT 805
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City | CHICAGO
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State | IL
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Zip | 60623
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Country | US
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Telephone | 920-750-3060
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Fax | 773-521-0570
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 54794
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 036130758
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License Number State | IL
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