MEDICARE: BAC MEDICAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1871484691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAC MEDICAL LLC

Provider Business Mailing Address
First Line	:	5900 N MAIN ST STE 3
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45415-3106
Country	:	US
Telephone Number	:	937-277-9371
Fax Number	:

Provider Business Practice Location Address
First Line	:	5900 N MAIN ST STE 3
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45415-3106
Country	:	US
Telephone Number	:	937-277-9371
Fax Number	:	937-277-7734

Authorized Official
Title or Position	:	OWNER / PHYSICIAN
Name	:	EDWARD P CLACK
Credential	:	DO
Telephone Number	:	937-277-9371

Provider Enumeration Date	:	07/10/2025
Last Update Date	:	07/10/2025

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Directions to “BAC MEDICAL LLC ” Practice Location

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