Provider Demographics
NPI:1326234113
Name:BAUM, RUSSELL SOLO (DOM)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:SOLO
Last Name:BAUM
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 LUISA ST STE A4
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-9830
Mailing Address - Country:US
Mailing Address - Phone:505-986-8802
Mailing Address - Fax:
Practice Address - Street 1:1305 LUISA ST STE A4
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-9830
Practice Address - Country:US
Practice Address - Phone:505-986-8802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM448171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist