Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 036051399 | IL |
Y | 208600000X | Surgeon | 036051399 | IL |
N | 2086S0120X | Pediatric Surgery | 036051399 | IL |
NPI | 1366437287 |
---|---|
Provider Name | Bruce Bauer |
First Address | Burr Ridge, IL 60527-5965 |
Second Address | Chicago, IL 60637-1443 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2005 |
Last Update Date | 23/08/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036051399 | (05) | IL |
1627123 | BCBS PROVIDER ID (01) | IL |
363283051 | OWCP PROVIDER ID (01) | IL |
E24554 | (02) | IL |