Provider Demographics
NPI:1508831157
Name:BACCUS, JOHN BENJAMIN III (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BENJAMIN
Last Name:BACCUS
Suffix:III
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 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-1069
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:500 ARCADE AVE STE 200
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2485
Practice Address - Country:US
Practice Address - Phone:574-294-8404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072136A207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201141150Medicaid
INM32727013OtherMEDICARE PTAN
IN201141150Medicaid
IN000000806974OtherBCBS BMG