Provider Demographics
NPI:1104269109
Name:BAUM, MICHAEL (MA, ATC, PES)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BAUM
Suffix:
Gender:M
Credentials:MA, ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:TCU SPORTS MEDICINE
Mailing Address - Street 2:TCU BOX 297600
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76129-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:TCU SPORTS MEDICINE
Practice Address - Street 2:TCU BOX 297600
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76129-0001
Practice Address - Country:US
Practice Address - Phone:817-257-6649
Practice Address - Fax:817-257-7323
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT56882255A2300X
MA23062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer