MEDICARE: ALVIN C BACON DO

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	207Q00000X	Family Medicine Physician	DO 00461	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	795932	OTHER	USFHP
2	400400	OTHER	BLUE CHIP
3	588384	OTHER	AETNA
4	2460971003	OTHER	CIGNA
5	0100801	OTHER	UHC
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104836568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALVIN C BACON DO

Provider Business Mailing Address
First Line	:	33 CHAMBLY AVE
Second Line	:
City	:	WARWICK
State	:	RI
Zip	:	02888-1805
Country	:	US
Telephone Number	:	401-534-6784
Fax Number	:	401-534-5460

Provider Business Practice Location Address
First Line	:	598 GREAT RD
Second Line	:	LOWER LEVEL
City	:	NORTH SMITHFIELD
State	:	RI
Zip	:	02896-6810
Country	:	US
Telephone Number	:	401-534-6784
Fax Number	:	401-534-5460

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	03/07/2012

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