Provider Demographics
NPI:1568229722
Name:BACCOUCHE, BASIL M
Entity Type:Individual
Prefix:
First Name:BASIL
Middle Name:M
Last Name:BACCOUCHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 LAKE FOREST DR W
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-8923
Mailing Address - Country:US
Mailing Address - Phone:734-883-7710
Mailing Address - Fax:
Practice Address - Street 1:4190 LAKE FOREST DR W
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-8923
Practice Address - Country:US
Practice Address - Phone:734-883-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program