Provider Demographics
NPI:1457352684
Name:BAUER, BRAD LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:LEE
Last Name:BAUER
Suffix:
Gender:M
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:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27289-0488
Mailing Address - Country:US
Mailing Address - Phone:336-627-0362
Mailing Address - Fax:336-627-0778
Practice Address - Street 1:618 S PIERCE ST
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5863
Practice Address - Country:US
Practice Address - Phone:336-635-6804
Practice Address - Fax:336-627-0778
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22601208800000X
WI37437-020208800000X
NC2013-01822208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL300276690OtherUNITED HEALTH CARE
AL51526132OtherBLUECROSS/BLUE SHIELD
AL009986035Medicaid
AL300276690OtherUNITED HEALTH CARE
ALHO1157Medicare UPIN
AL009986035Medicaid