Provider Demographics
NPI:1922202647
Name:BAUMAN, JACOB (MPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BAUMAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13537 BARRETT PARKWAY DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5899
Mailing Address - Country:US
Mailing Address - Phone:314-821-9126
Mailing Address - Fax:314-821-9142
Practice Address - Street 1:790 N US HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-5108
Practice Address - Country:US
Practice Address - Phone:314-972-1442
Practice Address - Fax:314-972-1533
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO223791511Medicare PIN
MO223791509Medicare PIN