=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881818201
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARSHALL G BACA MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2411 OSBORNE RD
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88220-3265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-885-2188
-----------------------------------------------------
Fax | 505-885-6486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2411 OSBORNE RD
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88220-3265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-885-2188
-----------------------------------------------------
Fax | 505-885-6486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARSHALL G BACA
-----------------------------------------------------
Credential | MD PC
-----------------------------------------------------
Telephone | 505-885-2188
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 96-5
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------