Individual provider · NPI-1

William Russell Bacon, MD

Radiology, Diagnostic Radiology · Eden Prairie, MN

NPI number1609014489
StatusActive
Last updated in NPPESAug 1, 2022

Details

NPI
1609014489
Entity type
Individual (NPI-1)
Name
William Russell Bacon
Credential
MD
Sex
Male
Sole proprietor
No
Enumeration date
Feb 2, 2009
Certification date
Aug 1, 2022
Last updated
Aug 1, 2022

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
2085R0202X Radiology, Diagnostic RadiologyME151240FLYes
2085R0202X Radiology, Diagnostic Radiology47338TN

Practice location

11995 Singletree Ln Ste 500
Eden Prairie, MN 55344-5349

Phone 952-595-1301 · Fax 612-294-4903

Mailing address

11995 Singletree Ln Ste 500
Eden Prairie, MN 55344-5349

Phone 952-595-1301 · Fax 612-294-4903

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