MEDICARE: ALBAN B BACCHUS MD INC

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	207R00000X	Internal Medicine Physician	ME0054352	FL

General Provider Information

NPI Number	:	1962412973
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBAN B BACCHUS MD INC

Provider Business Mailing Address
First Line	:	2889 10TH AVENUE NORTH
Second Line	:	SUITE 301
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-3045
Country	:	US
Telephone Number	:	561-966-2303
Fax Number	:	561-966-0714

Provider Business Practice Location Address
First Line	:	2889 10TH AVENUE NORTH
Second Line	:	SUITE 301
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-3045
Country	:	US
Telephone Number	:	561-966-2303
Fax Number	:	561-966-0714

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. ALBAN BERKLEY BACCHUS
Credential	:	MD
Telephone Number	:	561-966-2303

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	08/22/2020

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