MEDICARE: DR. JOHANNA BAEUERLE 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	207NS0135X	Procedural Dermatology Physician	151232	NY

General Provider Information

NPI Number	:	1346249794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHANNA BAEUERLE M.D.

Provider Business Mailing Address
First Line	:	253 PIERMONT AVE
Second Line	:
City	:	SOUTH NYACK
State	:	NY
Zip	:	10960-4610
Country	:	US
Telephone Number	:	845-353-4266
Fax Number	:

Provider Business Practice Location Address
First Line	:	326 N HIGHLAND AVE
Second Line	:
City	:	NYACK
State	:	NY
Zip	:	10960-1416
Country	:	US
Telephone Number	:	845-358-3300
Fax Number	:	845-358-3375

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

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	07/08/2007

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