Provider Demographics
NPI:1770571374
Name:BAUMBACH, GARY L (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:BAUMBACH
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-384-9083
Mailing Address - Fax:319-384-8054
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-384-9083
Practice Address - Fax:319-384-8054
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20899207ZN0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0163543Medicaid
IA1163543Medicaid
IA22687OtherWELLMARK BCBS
IA33899OtherWELLMARK BCBS
A02662Medicare UPIN
IA0163543Medicaid
IA1163543Medicaid
IAI9674Medicare PIN
IA220021117Medicare PIN