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General NPI Number Information
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NPI Number | 1508831157
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Entity Type | Individual
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Provider Name | JOHN BENJAMIN BACCUS III MD
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Gender | Male
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Dates
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Enumeration Date | 02/17/2006
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Last Update Date | 04/28/2023
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Provider Practice Location Address
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Address Line | 500 ARCADE AVE STE 200
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City | ELKHART
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State | IN
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Zip | 46514-2485
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Country | US
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Telephone | 574-294-8404
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Fax |
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Provider Business Mailing Address
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Address Line | 3245 HEALTH DR STE 100
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City | GRANGER
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State | IN
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Zip | 46530-1380
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Country | US
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Telephone | 574-647-1069
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Fax | 574-237-6069
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | 01072136A
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License Number State | IN
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