Basic Information
Provider Information | |||||||||
NPI: | 1336374321 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BACCHUS | ||||||||
FirstName: | RAFEENA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1111 BENFIELD BLVD | ||||||||
Address2: |   | ||||||||
City: | MILLERSVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 211083002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107295100 | ||||||||
FaxNumber: | 4436791382 | ||||||||
Practice Location | |||||||||
Address1: | 11055 LITTLE PATUXENT PKWY | ||||||||
Address2: | SUITE 104 | ||||||||
City: | COLUMBIA | ||||||||
State: | MD | ||||||||
PostalCode: | 210442896 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107402900 | ||||||||
FaxNumber: | 4107402955 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2009 | ||||||||
LastUpdateDate: | 01/17/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | D73688 | MD | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | D0073688 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P01102392 | 01 |   | RR MEDICARE PTAN | OTHER | V8260037 | 01 |   | CAREFIRST | OTHER |