Provider Demographics
NPI:1265576888
Name:BAKKE MEDICAL PC
Entity type:Organization
Organization Name:BAKKE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAISY
Authorized Official - Middle Name:S
Authorized Official - Last Name:ANGELES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-563-1033
Mailing Address - Street 1:21723 GARRISON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2368
Mailing Address - Country:US
Mailing Address - Phone:313-274-4215
Mailing Address - Fax:
Practice Address - Street 1:1039 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2016
Practice Address - Country:US
Practice Address - Phone:313-563-1033
Practice Address - Fax:313-563-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037608261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1361633Medicaid
MIA73600Medicare UPIN
MI1361633Medicaid