1265971063 NPI number — BASS MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265971063 NPI number — BASS MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BASS MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1265971063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2637 SHADELANDS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94598-2512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-948-8143
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 LA CASA VIA
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94598-3013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-930-9120
Provider Business Practice Location Address Fax Number:
925-930-9122
Provider Enumeration Date:
02/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
NAGESETTY
Authorized Official First Name:
RAJIV
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
925-932-6330

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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