Provider Demographics
NPI:1184192643
Name:BAUER, LUANN
Entity Type:Individual
Prefix:
First Name:LUANN
Middle Name:
Last Name:BAUER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 N WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-4443
Mailing Address - Country:US
Mailing Address - Phone:815-356-9900
Mailing Address - Fax:
Practice Address - Street 1:63 N WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-4443
Practice Address - Country:US
Practice Address - Phone:815-356-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20-1975060305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20-1975060OtherTAX ID #