Provider Demographics
NPI:1124011713
Name:BAUCH, THOMAS W (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:BAUCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11209 N TATUM BLVD
Mailing Address - Street 2:175
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3091
Mailing Address - Country:US
Mailing Address - Phone:602-652-8900
Mailing Address - Fax:602-652-8909
Practice Address - Street 1:11209 N TATUM BLVD
Practice Address - Street 2:175
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3091
Practice Address - Country:US
Practice Address - Phone:602-652-8900
Practice Address - Fax:602-652-8909
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ24557207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ393827Medicaid
AZ69682Medicare ID - Type Unspecified
AZ393827Medicaid