Healthcare Provider Details

I. General information

NPI: 1437118411
Provider Name (Legal Business Name): MICHAEL J BACCOLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 JEFFERSON AVE
SCRANTON PA
18510-1038
US

IV. Provider business mailing address

802 JEFFERSON AVENUE
SCRANTON PA
18510
US

V. Phone/Fax

Practice location:
  • Phone: 570-348-1118
  • Fax: 570-348-1118
Mailing address:
  • Phone: 570-348-1118
  • Fax: 570-348-1109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD062157L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: