Healthcare Provider Details

I. General information

NPI: 1083066989
Provider Name (Legal Business Name): MR. WILLIAM THOMAS BACUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4576 FENWICK DR
WARREN MI
48092-5112
US

IV. Provider business mailing address

4576 FENWICK DR
WARREN MI
48092-5112
US

V. Phone/Fax

Practice location:
  • Phone: 586-344-4098
  • Fax:
Mailing address:
  • Phone: 586-344-4098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: