Basic Information
| Provider Information | |||||||||
| NPI: | 1295840171 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACAK | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 876 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800400876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034937000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12605 E 16TH AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800452545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7208480000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 41822 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 29270057 | 05 | CO | MEDICAID |