1023143393 NPI number — FEODERIS N BASILIO MD

Table of content: FEODERIS N BASILIO MD (NPI 1023143393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023143393 NPI number — FEODERIS N BASILIO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASILIO
Provider First Name:
FEODERIS
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SEBERT
Provider Other First Name:
FEODERIS
Provider Other Middle Name:
BASILIO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1023143393
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 14TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31901-2131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-507-5437
Provider Business Mailing Address Fax Number:
706-507-5499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 14TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31901-2131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-507-5437
Provider Business Practice Location Address Fax Number:
706-507-5499
Provider Enumeration Date:
02/23/2007

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: 2080A0000X , with the licence number:  050092 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000958702A . This is a "PEACH STATE HEALTH PLAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000958702A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52009279 . This is a "BCBS GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 306085 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 60103339 . This is a "BCBS AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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