Provider Demographics
NPI:1578981189
Name:BAUKUS, STEPHANIE JANE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JANE
Last Name:BAUKUS
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 1:1540 LAKE LANSING RD
Mailing Address - Street 2:STE 201
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3757
Mailing Address - Country:US
Mailing Address - Phone:517-913-3900
Mailing Address - Fax:517-913-3901
Practice Address - Street 1:401 W GREENLAWN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2819
Practice Address - Country:US
Practice Address - Phone:517-975-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021214207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program