MEDICARE: JAMES P. BACON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	35-05-0204-B	OH
2	207RI0011X	Interventional Cardiology Physician	35.050204	OH
3	207RC0000X	Cardiovascular Disease Physician	35.050204	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063413474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES P. BACON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 7527
Second Line	:
City	:	DUBLIN
State	:	OH
Zip	:	43017-0727
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	335 GLESSNER AVE
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44903-2269
Country	:	US
Telephone Number	:	419-524-8151
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	09/08/2023

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