MEDICARE: BASELINE NEUROLOGY, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	204R00000X	Electrodiagnostic Medicine Physician
2	2084N0400X	Neurology Physician
3	246ZE0600X	Electroneurodiagnostic Specialist/Technologist
4	2084N0600X	Clinical Neurophysiology Physician

General Provider Information

NPI Number	:	1205595634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BASELINE NEUROLOGY, PC

Provider Business Mailing Address
First Line	:	1141 N LOOP 1604 E #105-612
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232
Country	:	US
Telephone Number	:	210-598-4277
Fax Number	:

Provider Business Practice Location Address
First Line	:	721 ESPLANADE UNIT 407
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-4651
Country	:	US
Telephone Number	:	210-598-4277
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CLIENT EXPERIENCE
Name	:	ROXANNA LAROQUE
Credential	:
Telephone Number	:	210-598-4277

Provider Enumeration Date	:	12/13/2021
Last Update Date	:	09/14/2022

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