Basic Information
| Provider Information | |||||||||
| NPI: | 1699827303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACCARI | ||||||||
| FirstName: | ELSI | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 SANDPOINT RD | ||||||||
| Address2: | |||||||||
| City: | MUNISING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498621406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063874110 | ||||||||
| FaxNumber: | 9063872825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 SANDPOINT RD | ||||||||
| Address2: | |||||||||
| City: | MUNISING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498621406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063874110 | ||||||||
| FaxNumber: | 9063872825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101009526 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 18403 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5170118 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |