Provider Demographics
NPI:1851488720
Name:BAUCOM, MATTHEW JOSEPH (RPSGT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:BAUCOM
Suffix:
Gender:M
Credentials:RPSGT
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Mailing Address - Street 1:1580 W PORTVIEW DR
Mailing Address - Street 2:APT #2
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074
Mailing Address - Country:US
Mailing Address - Phone:262-894-6833
Mailing Address - Fax:
Practice Address - Street 1:11649 N PORT WASHINGTON RD
Practice Address - Street 2:STE 109
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092
Practice Address - Country:US
Practice Address - Phone:262-241-8022
Practice Address - Fax:262-241-8047
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic