Basic Information
| Provider Information | |||||||||
| NPI: | 1205891744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACALA | ||||||||
| FirstName: | AGNES | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 760 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475010760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122542760 | ||||||||
| FaxNumber: | 8122548636 | ||||||||
| Practice Location | |||||||||
| Address1: | 12546 E US HIGHWAY 50 | ||||||||
| Address2: | |||||||||
| City: | LOOGOOTEE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475535220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122955095 | ||||||||
| FaxNumber: | 8122959403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32413 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01043434A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00711471 | 01 | KY | RAILROAD MEDICARE - KY | OTHER | P00298628 | 01 | IN | RAILROAD MEDICARE | OTHER | 200072110 | 05 | IN | MEDICAID | 64130602 | 05 | KY | MEDICAID |