Provider Demographics
NPI:1962412973
Name:ALBAN B BACCHUS MD INC
Entity type:Organization
Organization Name:ALBAN B BACCHUS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBAN
Authorized Official - Middle Name:BERKLEY
Authorized Official - Last Name:BACCHUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-966-2303
Mailing Address - Street 1:2889 10TH AVENUE NORTH
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3045
Mailing Address - Country:US
Mailing Address - Phone:561-966-2303
Mailing Address - Fax:561-966-0714
Practice Address - Street 1:2889 10TH AVENUE NORTH
Practice Address - Street 2:SUITE 301
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-3045
Practice Address - Country:US
Practice Address - Phone:561-966-2303
Practice Address - Fax:561-966-0714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0054352207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C49138Medicare UPIN
FL09244Medicare ID - Type Unspecified