Provider Demographics
NPI:1124212527
Name:MELISSA N. BACCHUS, MD, PLLC
Entity Type:Organization
Organization Name:MELISSA N. BACCHUS, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:N
Authorized Official - Last Name:BACCHUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-767-7930
Mailing Address - Street 1:4607 MACCORKLE AVE SW
Mailing Address - Street 2:MEDICAL PAVILION SUITE 204
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1364
Mailing Address - Country:US
Mailing Address - Phone:304-767-7930
Mailing Address - Fax:304-767-7935
Practice Address - Street 1:4607 MACCORKLE AVE SW
Practice Address - Street 2:MEDICAL PAVILION SUITE 204
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1364
Practice Address - Country:US
Practice Address - Phone:304-767-7930
Practice Address - Fax:304-767-7935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22766208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty