Provider Demographics
NPI:1619062684
Name:BAUCOM, BRIAN MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:BAUCOM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 SHIPYARD BLVD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-8023
Mailing Address - Country:US
Mailing Address - Phone:910-791-0396
Mailing Address - Fax:
Practice Address - Street 1:1717 SHIPYARD BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8023
Practice Address - Country:US
Practice Address - Phone:910-791-0396
Practice Address - Fax:910-791-0818
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212129Medicaid
NC2504023Medicare PIN