Provider Demographics
NPI:1578533840
Name:TRESCHUK-BAHN, JACQUELINE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:A
Last Name:TRESCHUK-BAHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:A
Other - Last Name:TRESCHUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:70 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-334-6071
Mailing Address - Fax:573-334-4739
Practice Address - Street 1:70 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4928
Practice Address - Country:US
Practice Address - Phone:573-334-6071
Practice Address - Fax:573-334-4739
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120299232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000553574OtherBCBS ANTHEM
IL036078816Medicaid
KY7100041220Medicaid
KY00151036Medicare PIN
KY00503013Medicare PIN
IL036078816Medicaid
KYP00466314Medicare PIN
ILE19168Medicare UPIN
KY7100041220Medicaid