Provider Demographics
NPI:1972684207
Name:BATH, JEFFREY J (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:J
Last Name:BATH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:11995 SINGLETREE LN
Mailing Address - Street 2:SUITE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:67 IDE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:MA
Practice Address - Zip Code:01267-2814
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2238572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA600343OtherMASS. HARVARD-PILGRIM
NY01302661865Medicaid
MA000000031706OtherMASS.-BMC HEALTHNET
MAI38426Medicare UPIN
MAJ29016OtherMASS. BC/BS
VT1011597Medicaid
MA2103818Medicaid
MAA39003Medicare ID - Type UnspecifiedMA MEDICARE