Provider Demographics
NPI:1598732133
Name:BACILLA, PHILLIP RAY JR (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:RAY
Last Name:BACILLA
Suffix:JR
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 1:3351 MASONIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3842
Mailing Address - Country:US
Mailing Address - Phone:318-473-9556
Mailing Address - Fax:318-441-8339
Practice Address - Street 1:3351 MASONIC DRIVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3842
Practice Address - Country:US
Practice Address - Phone:318-473-9556
Practice Address - Fax:318-441-8339
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD 020542207X00000X
LAMD020542207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Not Answered207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1662496Medicaid
LA1662496Medicaid
E53846Medicare UPIN