Provider Demographics
NPI:1437271012
Name:BAUER PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:BAUER PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P.T.
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-929-9712
Mailing Address - Street 1:355 N PETERS AVE
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-8258
Mailing Address - Country:US
Mailing Address - Phone:920-929-9712
Mailing Address - Fax:920-929-9715
Practice Address - Street 1:355 N PETERS AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8258
Practice Address - Country:US
Practice Address - Phone:920-929-9712
Practice Address - Fax:920-929-9715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5173024261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40340300Medicaid
WI40340300Medicaid
WIP19497Medicare UPIN