1336179910 NPI number — MICHAEL T BASS MD

Table of content: MICHAEL T BASS MD (NPI 1336179910)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336179910 NPI number — MICHAEL T BASS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASS
Provider First Name:
MICHAEL
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336179910
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1720 HIGHWAY 59 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THIEF RIVER FALLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56701-4331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-681-4747
Provider Business Mailing Address Fax Number:
218-683-2595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1720 HIGHWAY 59 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THIEF RIVER FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56701-4331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-681-4747
Provider Business Practice Location Address Fax Number:
218-683-2595
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  43101 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 73Q72BA . This is a "MNBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0701567 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: ND200210 . This is a "LHS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP38654 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 141993 . This is a "UCARE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1172372 . This is a "AMERICA'S PPO/ARAZ #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 12150 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20477 . This is a "NDBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5041522000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA9021026958 . This is a "PREFERRED ONE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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