MEDICARE: DR. FREDERICK DURLIN BAUSCHARD 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	207N00000X	Dermatology Physician	R4202	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0300003	OTHER	MO	UNITED HEALTHCARE
2	17657	OTHER	MO	BLUE SHIELD

General Provider Information

NPI Number	:	1669478558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FREDERICK DURLIN BAUSCHARD M.D.

Provider Business Mailing Address
First Line	:	6451 CHIPPEWA ST
Second Line	:	STE 2
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-2104
Country	:	US
Telephone Number	:	314-832-6803
Fax Number	:	314-832-8072

Provider Business Practice Location Address
First Line	:	6451 CHIPPEWA ST
Second Line	:	STE 2
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-2104
Country	:	US
Telephone Number	:	314-832-6803
Fax Number	:	314-832-8072

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

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	07/08/2007

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