Provider Demographics
NPI:1558576165
Name:GEORGE BACA MD, LLC
Entity Type:Organization
Organization Name:GEORGE BACA MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-872-2929
Mailing Address - Street 1:5808 MCLEOD RD NE
Mailing Address - Street 2:SUITE K
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2455
Mailing Address - Country:US
Mailing Address - Phone:505-872-2929
Mailing Address - Fax:505-872-9503
Practice Address - Street 1:5808 MCLEOD RD NE
Practice Address - Street 2:SUITE K
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2455
Practice Address - Country:US
Practice Address - Phone:505-872-2929
Practice Address - Fax:505-872-9503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM89-52084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty