Basic Information
| Provider Information | |||||||||
| NPI: | 1669443057 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BACIC | ||||||||
| FirstName: | MIMA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1847 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494431847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317274444 | ||||||||
| FaxNumber: | 2317274451 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E SHERMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316723883 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 06/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301077001 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 4301077001 | MI | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.