Provider Demographics
NPI:1699209296
Name:BACCHUS, AHSHEEMA ASMAA (MD)
Entity Type:Individual
Prefix:
First Name:AHSHEEMA
Middle Name:ASMAA
Last Name:BACCHUS
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8617
Mailing Address - Fax:
Practice Address - Street 1:32845 RADIO RD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-3977
Practice Address - Country:US
Practice Address - Phone:352-504-3453
Practice Address - Fax:352-504-3454
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME159085207Q00000X
SC40881207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC408810Medicaid