Provider Demographics
NPI:1881818201
Name:MARSHALL G BACA MD PC
Entity Type:Organization
Organization Name:MARSHALL G BACA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:505-885-2188
Mailing Address - Street 1:2411 OSBORNE RD
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3265
Mailing Address - Country:US
Mailing Address - Phone:505-885-2188
Mailing Address - Fax:505-885-6486
Practice Address - Street 1:2411 OSBORNE RD
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3265
Practice Address - Country:US
Practice Address - Phone:505-885-2188
Practice Address - Fax:505-885-6486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM96-5174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH5181Medicaid
NM4168540001Medicare NSC
NMF13673Medicare UPIN
NM=========Medicare ID - Type Unspecified