MEDICARE: TARIF BAKDASH 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	208000000X	Pediatrics Physician	2012014535	MO
2	208000000X	Pediatrics Physician	4301055614	MI
3	208000000X	Pediatrics Physician	12298	MT
4	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	4301055614	MI
5	2084N0400X	Neurology Physician	63034	WI
6	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	63034	WI
7	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	24539	MS
8	2084N0600X	Clinical Neurophysiology Physician	58549	KY
9	2084N0600X	Clinical Neurophysiology Physician	63034	WI
10	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	58549	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	431560263	OTHER	MO	TRICARE
2	P01110482	OTHER	MO	RR MCR
3	12298	OTHER	MT	LICENSE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104141712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARIF BAKDASH M.D.

Provider Business Mailing Address
First Line	:	2195 HARRODSBURG RD FL 2
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40504-3516
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2195 HARRODSBURG RD FL 2
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40504-3516
Country	:	US
Telephone Number	:	859-562-1868
Fax Number	:	859-257-0421

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

Provider Enumeration Date	:	04/07/2010
Last Update Date	:	11/02/2023

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