1477889624 NPI number — WILLIE T BASCO PT

Table of content: WILLIE T BASCO PT (NPI 1477889624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477889624 NPI number — WILLIE T BASCO PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASCO
Provider First Name:
WILLIE
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1477889624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 W 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARCUS HOOK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19061-4513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-859-8850
Provider Business Mailing Address Fax Number:
610-859-7876

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 DEAK DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19977-1268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-659-5700
Provider Business Practice Location Address Fax Number:
302-659-5703
Provider Enumeration Date:
10/22/2009

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: 225100000X , with the licence number:  J10002517 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000020536 . This is a "DPCI" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 1477889624 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3768331000 . This is a "IBC" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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