Basic Information
Provider Information | |||||||||
NPI: | 1265400717 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAUER | ||||||||
FirstName: | AUDREY | ||||||||
MiddleName: | G | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BOLANOWSKI | ||||||||
OtherFirstName: | AUDREY | ||||||||
OtherMiddleName: | G | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 11945 SAN JOSE BLVD | ||||||||
Address2: | STE 300 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322231627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043961725 | ||||||||
FaxNumber: | 9043964893 | ||||||||
Practice Location | |||||||||
Address1: | 4012 N 9TH AVE | ||||||||
Address2: |   | ||||||||
City: | PENSACOLA | ||||||||
State: | FL | ||||||||
PostalCode: | 325032824 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8504444777 | ||||||||
FaxNumber: | 8504343387 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/10/2006 | ||||||||
LastUpdateDate: | 08/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0101235128 | VA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 53119 | CO | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 145718 | FL | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 19730381 | 05 | CO |   | MEDICAID | 024177 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER |