1972598506 NPI number — DR. CLAYTON A BASS MD

Table of content: DR. CLAYTON A BASS MD (NPI 1972598506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972598506 NPI number — DR. CLAYTON A BASS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASS
Provider First Name:
CLAYTON
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
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:
1972598506
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
370 E SOUTH TEMPLE STE 260
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84111-1290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-463-7415
Provider Business Mailing Address Fax Number:
801-463-7341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5475 S 500 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84405-6905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-463-7415
Provider Business Practice Location Address Fax Number:
801-463-7341
Provider Enumeration Date:
09/20/2005

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: 207P00000X , with the licence number:  045167 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 6068769-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: 13154 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000784924D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06559318 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52755548-002 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1490261 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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