MEDICARE: DR. JAKE D BAUWENS 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	390200000X	Student in an Organized Health Care Education/Training Program
2	207X00000X	Orthopaedic Surgery Physician	65967-20	WI

General Provider Information

NPI Number	:	1639564586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAKE D BAUWENS M.D

Provider Business Mailing Address
First Line	:	2500 N MAYFAIR RD STE 500
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-1415
Country	:	US
Telephone Number	:	414-257-1772
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 N MAYFAIR RD STE 500
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-1415
Country	:	US
Telephone Number	:	414-257-1772
Fax Number	:

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

Provider Enumeration Date	:	03/30/2015
Last Update Date	:	07/30/2021

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