MEDICARE: MR. BASIL J BACCASH P.T.

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	225100000X	Physical Therapist	40QA00241800	NJ

General Provider Information

NPI Number	:	1730184037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BASIL J BACCASH P.T.

Provider Business Mailing Address
First Line	:	PO BOX 1014
Second Line	:
City	:	CLARK
State	:	NJ
Zip	:	07066-1014
Country	:	US
Telephone Number	:	732-855-9751
Fax Number	:	732-855-9755

Provider Business Practice Location Address
First Line	:	2145 ROUTE 35 STE 24
Second Line	:
City	:	HOLMDEL
State	:	NJ
Zip	:	07733-1163
Country	:	US
Telephone Number	:	732-264-9494
Fax Number	:	732-855-9755

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

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	07/21/2022

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