Provider Demographics
NPI:1710176474
Name:BACCHUS, ALBAN BERKLEY (MD)
Entity Type:Individual
Prefix:
First Name:ALBAN
Middle Name:BERKLEY
Last Name:BACCHUS
Suffix:
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 1:2889 10TH AVE N
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3045
Mailing Address - Country:US
Mailing Address - Phone:561-966-2303
Mailing Address - Fax:561-966-0714
Practice Address - Street 1:2889 10TH AVE N
Practice Address - Street 2:SUITE 301
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-3045
Practice Address - Country:US
Practice Address - Phone:561-966-2303
Practice Address - Fax:561-966-0714
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0054352207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063148500Medicaid
09244Medicare PIN
C49138Medicare UPIN