Healthcare Provider Details

I. General information

NPI: 1164519823
Provider Name (Legal Business Name): GEORGE BACALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 HAZARD AVE
ENFIELD CT
06082
US

IV. Provider business mailing address

170 HAZARD AVE
ENFIELD CT
06082
US

V. Phone/Fax

Practice location:
  • Phone: 860-763-4001
  • Fax: 860-749-5592
Mailing address:
  • Phone: 860-763-4001
  • Fax: 860-749-5592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number017896
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: