Healthcare Provider Details

I. General information

NPI: 1780631549
Provider Name (Legal Business Name): MARK BACIGAL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

46815 CREEKS BND
CANTON MI
48188-2384
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number5101009892
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: