Provider Demographics
NPI:1326087529
Name:BACEVICH, THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:BACEVICH
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 1:7905 CALUMET AVE
Mailing Address - Street 2:HAMMOND CLINIC LLC
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1215
Mailing Address - Country:US
Mailing Address - Phone:219-836-7214
Mailing Address - Fax:219-836-5030
Practice Address - Street 1:7905 CALUMET AVE
Practice Address - Street 2:HAMMOND CLINIC LLC
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1215
Practice Address - Country:US
Practice Address - Phone:219-836-7214
Practice Address - Fax:219-836-5030
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035070A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100204410AMedicaid
INM400047772Medicare PIN
IN473060DMedicare PIN
IN100204410AMedicaid