Provider Demographics
NPI:1467495085
Name:MC RAE, BART L (MD)
Entity Type:Individual
Prefix:
First Name:BART
Middle Name:L
Last Name:MC RAE
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 1:7425 N MONA LISA RD
Mailing Address - Street 2:APT 59
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-4526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARONDELET HOLY CROSS HOSPITAL
Practice Address - Street 2:1171 W. TARGET RANGE ROAD
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621
Practice Address - Country:US
Practice Address - Phone:520-287-2771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050410207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ198368-01Medicaid
AZ21837Medicare ID - Type Unspecified
AZF41791Medicare UPIN