Provider Demographics
NPI:1134110588
Name:BACESKI, DEBORAH A (MD)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:A
Last Name:BACESKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-2251
Mailing Address - Country:US
Mailing Address - Phone:814-443-1451
Mailing Address - Fax:814-444-8100
Practice Address - Street 1:105 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-2251
Practice Address - Country:US
Practice Address - Phone:814-443-1451
Practice Address - Fax:814-444-8100
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020766E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA110031490OtherPALMETTO GBA
PA25-1381943OtherUMWA
PA251381943OtherUPMC
PA000153392OtherKEYSTONE HEALTH PLAN WEST
PABA153392OtherHIGHMARK BLUE SHIELD
PABA153392OtherHIGHMARK BLUE SHIELD