Provider Demographics
NPI:1295946473
Name:BAUER, KIMBERLY ANN (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:BAUER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3192
Mailing Address - Country:US
Mailing Address - Phone:815-758-8674
Mailing Address - Fax:815-758-7298
Practice Address - Street 1:1124 ESSINGTON RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8423
Practice Address - Country:US
Practice Address - Phone:815-744-8554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-27
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036130506207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400368523OtherMEDICARE INDIVIDUAL