MEDICARE: DR. GREGORY ALAN BAUM 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	208200000X	Plastic Surgery Physician	216811-1	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RB7625	OTHER	NY	MEDICARE PTAN

General Provider Information

NPI Number	:	1720083090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY ALAN BAUM M.D.

Provider Business Mailing Address
First Line	:	5898 BRIDGE ST
Second Line	:
City	:	EAST SYRACUSE
State	:	NY
Zip	:	13057
Country	:	US
Telephone Number	:	315-663-0112
Fax Number	:

Provider Business Practice Location Address
First Line	:	5898 BRIDGE ST
Second Line	:
City	:	EAST SYRACUSE
State	:	NY
Zip	:	13057-1305
Country	:	US
Telephone Number	:	315-663-0112
Fax Number	:	315-663-0132

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

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	05/11/2020

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