Provider Demographics
NPI:1477584639
Name:BACARES, MICHELLE KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:KATHLEEN
Last Name:BACARES
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:PO BOX 13373
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212
Mailing Address - Country:US
Mailing Address - Phone:518-650-6674
Mailing Address - Fax:518-641-1651
Practice Address - Street 1:5 PINE WEST PLZ STE 512
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5587
Practice Address - Country:US
Practice Address - Phone:518-650-6674
Practice Address - Fax:518-641-1651
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002095082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY53088AOtherMVP PROVIDER
000412260001OtherBLUE SHIELD
NY00209508Medicaid
P00336520Medicare ID - Type UnspecifiedMEDICARE RAILROAD
NY00209508Medicaid
RB1005Medicare ID - Type Unspecified