Basic Information
| Provider Information | |||||||||
| NPI: | 1053335984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUTISTA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 29TH AVE N | ||||||||
| Address2: | STE 202 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | 6153277940 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 29TH AVE N | ||||||||
| Address2: | STE 202 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | 6153277940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/05/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 4301054992 | MI | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 42553 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0508278902 | 01 | MI | BCBS | OTHER | 4114073-10 | 05 | MI | MEDICAID | 9910831 | 05 | AL | MEDICAID | 3000254 | 05 | TN | MEDICAID | 2989097-10 | 05 | MI | MEDICAID | 4153878 | 01 | TN | BCBS OF TN | OTHER | 7100012340 | 05 | KY | MEDICAID |