Provider Demographics
NPI:1366528838
Name:BACON, ROSS NOEL (MD)
Entity type:Individual
Prefix:DR
First Name:ROSS
Middle Name:NOEL
Last Name:BACON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:1205 S GRANGE AVE STE 407
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0410
Practice Address - Country:US
Practice Address - Phone:605-328-8900
Practice Address - Fax:605-328-8901
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28247207R00000X, 207RC0200X, 207RP1001X, 207RS0012X
SD4302207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025572500OtherMEDICAID
SD4992607OtherBLUE CROSS BLUE SHIELD
IA71249OtherBLUE CROSS BLUE SHIELD
NE10025572500OtherMEDICAID