Provider Demographics
NPI:1811093073
Name:BARDACK, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BARDACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE STE 2222
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4375
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:
Practice Address - Street 1:2400 TUCKER AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-1734
Practice Address - Fax:505-272-1736
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD20060797207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109696Medicaid
IL212183Medicare ID - Type Unspecified
H48185Medicare UPIN