Provider Demographics
NPI:1164474763
Name:BAUER, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BAUER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S MOUNT AUBURN RD STE 418
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4911
Mailing Address - Country:US
Mailing Address - Phone:573-332-6000
Mailing Address - Fax:
Practice Address - Street 1:150 S MOUNT AUBURN RD
Practice Address - Street 2:STE 418
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4911
Practice Address - Country:US
Practice Address - Phone:573-332-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112733208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203827522Medicaid
AR160304001Medicaid
146167OtherBCBS
KY7100013060Medicaid
P00233446OtherRAILROAD MEDICARE
705383OtherHEALTHLINK
705383OtherHEALTHLINK
929863247Medicare PIN