=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942326020
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVALON BIOTECHNICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 11/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3364 KAY RD
-----------------------------------------------------
City | LAKESIDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85929-5405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-368-8200
-----------------------------------------------------
Fax | 928-368-8208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1912
-----------------------------------------------------
City | SHOW LOW
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85902-1912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-368-8200
-----------------------------------------------------
Fax | 928-368-8208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARC A BAUDER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 928-368-8200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 15235
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------