Provider Demographics
NPI:1912965799
Name:BACON, MICHAEL J (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:BACON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1937 M 119
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8913
Mailing Address - Country:US
Mailing Address - Phone:231-348-9200
Mailing Address - Fax:231-348-9876
Practice Address - Street 1:1937 M 119
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8913
Practice Address - Country:US
Practice Address - Phone:231-348-9200
Practice Address - Fax:231-348-9876
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0M81400Medicare ID - Type Unspecified
MI3238020 11Medicaid
MI080B410330OtherBCBS GROUP BILLING #
MI0852400164OtherBCBS PIN
MIP44540OtherBLUE CARE NETWORK
E26344Medicare UPIN