Provider Demographics
NPI:1902837669
Name:RANDI H BACULI MD PA
Entity Type:Organization
Organization Name:RANDI H BACULI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BACULI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-423-0977
Mailing Address - Street 1:2504 FIGTREE LN
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-4858
Mailing Address - Country:US
Mailing Address - Phone:972-423-0977
Mailing Address - Fax:972-578-1867
Practice Address - Street 1:1151 N BUCKNER BLVD
Practice Address - Street 2:407
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-3426
Practice Address - Country:US
Practice Address - Phone:972-423-0977
Practice Address - Fax:972-578-1867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2117174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0010PZOtherBCBS
TX149294403Medicaid
TX7477332OtherAETNA
TX172916201Medicaid
TXP00003881OtherRAILROAD MEDICARE
TXH43784Medicare UPIN
TX149294403Medicaid
TX7477332OtherAETNA