Provider Demographics
NPI:1619238490
Name:TERRY SCOTT BAUL, M.D., P.C.
Entity Type:Organization
Organization Name:TERRY SCOTT BAUL, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-885-6833
Mailing Address - Street 1:17751 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1329
Mailing Address - Country:US
Mailing Address - Phone:313-885-6833
Mailing Address - Fax:313-885-1268
Practice Address - Street 1:17751 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1329
Practice Address - Country:US
Practice Address - Phone:313-885-6833
Practice Address - Fax:313-885-1268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042171208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0821263OtherBCBSM
MI1624055Medicaid
B44190Medicare UPIN
MI1624055Medicaid