Provider Demographics
NPI:1285634154
Name:BACCHUS, AMY CLAIRE (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:CLAIRE
Last Name:BACCHUS
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 1:6585 S YALE AVE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8384
Mailing Address - Country:US
Mailing Address - Phone:918-494-9288
Mailing Address - Fax:918-494-9191
Practice Address - Street 1:6585 S YALE AVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8384
Practice Address - Country:US
Practice Address - Phone:918-494-9288
Practice Address - Fax:918-494-9191
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24281207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200054560AMedicaid
OK450778109OtherTRICARE
OKH35830Medicare UPIN
OK243520701Medicare PIN
OK450778109OtherTRICARE