Provider Demographics
NPI:1073591855
Name:BACON, RICHARD W (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:BACON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW HOLLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17557-1426
Mailing Address - Country:US
Mailing Address - Phone:717-354-4671
Mailing Address - Fax:717-354-2478
Practice Address - Street 1:676 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW HOLLAND
Practice Address - State:PA
Practice Address - Zip Code:17557-1426
Practice Address - Country:US
Practice Address - Phone:717-354-4671
Practice Address - Fax:717-354-2478
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017512E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01485901OtherCAPITAL BLUE CROSS
PA51411 S1QIOtherGEISINGER HEALTH PLAN
PA50060205OtherCAPITAL BLUE CROSS
PA064029OtherHIGHMARK BLUE SHIELD
PAP002645OtherGATEWAY HEALTH PLAN
PA0007658180001Medicaid
PA0007658180004Medicaid
PA50043833OtherCAPITAL BLUE CROSS
PA50046244OtherCAPITAL BLUE CROSS
PA50068264OtherCAPITAL BLUE CROSS
PA50041793OtherCAPITAL BLUE CROSS
PAC28692OtherHEALTH ASSURANCE
PA50061963OtherCAPITAL BLUE CROSS
PA50046244OtherCAPITAL BLUE CROSS
PA064029GEDMedicare PIN
PA01485901OtherCAPITAL BLUE CROSS
PA0007658180004Medicaid