Basic Information
| Provider Information | |||||||||
| NPI: | 1366528838 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACON | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | NOEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053286585 | ||||||||
| FaxNumber: | 6053286512 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 S GRANGE AVE STE 407 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571050410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053288900 | ||||||||
| FaxNumber: | 6053288901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2013 | ||||||||
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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 | 207R00000X | 28247 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 28247 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 28247 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | 28247 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 4302 | SD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 10025572500 | 01 | NE | MEDICAID | OTHER | 4992607 | 01 | SD | BLUE CROSS BLUE SHIELD | OTHER | 71249 | 01 | IA | BLUE CROSS BLUE SHIELD | OTHER |