Basic Information
| Provider Information | |||||||||
| NPI: | 1891138004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACSIK-CAMPBELL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BACSIK | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 112 HELEN ST | ||||||||
| Address2: | |||||||||
| City: | SAUK CITY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535831168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086433351 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 112 HELEN ST | ||||||||
| Address2: | |||||||||
| City: | SAUK CITY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535831101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086433351 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2013 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 63309-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.