Basic Information
| Provider Information | |||||||||
| NPI: | 1063639839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASS | ||||||||
| FirstName: | LEON | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376620009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238572066 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 W STONE DR STE 1J | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233787645 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 01/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 48080 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | 48080 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 48080 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | 48080 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207R00000X | 001195 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 0101251956 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1063639839 | 05 | VA | MEDICAID | 7100389480 | 05 | KY | MEDICAID | 1528609 | 05 | TN | MEDICAID | 1063639839 | 05 | NC | MEDICAID |