MEDICARE: DR. RALPH WILLARD BAUCUM III M.D.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	019833	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295735793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RALPH WILLARD BAUCUM III M.D.

Provider Business Mailing Address
First Line	:	PO BOX 51008
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71135-1008
Country	:	US
Telephone Number	:	318-798-9400
Fax Number	:	318-213-7276

Provider Business Practice Location Address
First Line	:	1453 E BERT KOUN LOOP
Second Line	:	STE 112
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-6800
Country	:	US
Telephone Number	:	318-222-3695
Fax Number	:	318-424-0717

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	01/30/2017

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