Provider Demographics
NPI:1003836917
Name:BACCI, ELAINE (DO)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:BACCI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 HIGHWAY 35
Mailing Address - Street 2:STE 324
Mailing Address - City:SEA GIRT
Mailing Address - State:NJ
Mailing Address - Zip Code:08750-1011
Mailing Address - Country:US
Mailing Address - Phone:732-974-1980
Mailing Address - Fax:732-974-2117
Practice Address - Street 1:565 HWY 35 NORTH
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701
Practice Address - Country:US
Practice Address - Phone:732-219-7140
Practice Address - Fax:732-219-7177
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB66800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7966300Medicaid
028392Medicare ID - Type Unspecified
F57774Medicare UPIN