1073591855 NPI number — RICHARD W BACON M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073591855 NPI number — RICHARD W BACON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACON
Provider First Name:
RICHARD
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073591855
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
676 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HOLLAND
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17557-1426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-354-4671
Provider Business Mailing Address Fax Number:
717-354-2478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
676 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HOLLAND
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17557-1426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-354-4671
Provider Business Practice Location Address Fax Number:
717-354-2478
Provider Enumeration Date:
01/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD017512E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01485901 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 51411 S1QI . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50060205 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 064029 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P002645 . This is a "GATEWAY HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0007658180001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0007658180004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50043833 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50046244 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50068264 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50041793 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: C28692 . This is a "HEALTH ASSURANCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50061963 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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