Provider Demographics
NPI:1437118411
Name:BACCOLI, MICHAEL J (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:BACCOLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 JEFFERSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510
Mailing Address - Country:US
Mailing Address - Phone:570-348-1118
Mailing Address - Fax:570-348-1109
Practice Address - Street 1:802 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1038
Practice Address - Country:US
Practice Address - Phone:570-348-1118
Practice Address - Fax:570-348-1118
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062157L2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G55003Medicare UPIN
673735Medicare ID - Type Unspecified