Provider Demographics
NPI:1700906039
Name:R.L. BAUTISTA, INC.
Entity Type:Organization
Organization Name:R.L. BAUTISTA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGELIO
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:660-263-2650
Mailing Address - Street 1:1145 S MORLEY ST
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-1948
Mailing Address - Country:US
Mailing Address - Phone:660-263-2650
Mailing Address - Fax:660-263-9010
Practice Address - Street 1:1145 S MORLEY ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-1948
Practice Address - Country:US
Practice Address - Phone:660-263-2650
Practice Address - Fax:660-263-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33051208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1636OtherANTHEM BCBS
MOCT0809OtherTRAVELERS RR MEDICARE