NPIMap

Individual provider Active NPI

Harold Mustapha Bacchus Jr., MD

  • Family Medicine Physician
  • Fort Wayne, IN
National Provider Identifier
1881654523
Registry record updated Dec 20, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
01034833 Issued in IN
Practice address
1719 Cremer Ave
Fort Wayne, IN 46818-1052
Phone
(260) 490-9150
Fax
(260) 490-9195
NPI assigned
Mar 25, 2006
Last updated
Dec 20, 2009By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 20, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 01034833 IN Primary

Addresses

Primary practice location

1719 Cremer Ave
Fort Wayne, IN 46818-1052

Mailing address

12002 Woodbourne CT
Ft Wayne, IN 46845-1952
Phone (260) 637-5303

Other identifiers 2

IdentifierTypeStateIssuer
000000634416OtherINANTHEM
200027190MedicaidIN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Depot Emergency Physicians Past Accepting new patients
Michigan Em-I Medical Services, P.C. Past Accepting new patients
Preferred Emergency Physicians Past Accepting new patients
Nufinity, LLC Past Accepting new patients
Michigan Em-I Medical Services, P.C. Past Accepting new patients
Flowing Waters Emergency Physicians Past Accepting new patients
Emergency Medicine of Indiana Past Accepting new patients

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1143244800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1261267200000",
    "number": "1881654523",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12002 WOODBOURNE CT",
            "city": "FT WAYNE",
            "state": "IN",
            "postal_code": "468451952",
            "telephone_number": "260-637-5303",
            "fax_number": "260-490-9195"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1719 CREMER AVE",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468181052",
            "telephone_number": "260-490-9150",
            "fax_number": "260-490-9195"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BACCHUS",
        "first_name": "HAROLD",
        "middle_name": "MUSTAPHA",
        "name_prefix": "Dr.",
        "name_suffix": "Jr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-03-25",
        "last_updated": "2009-12-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IN",
            "license": "01034833",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "000000634416",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200027190",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Wayne, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 20, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.