Basic Information
| Provider Information | |||||||||
| NPI: | 1124139936 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASTAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 CENTERVILLE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028864376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017374581 | ||||||||
| FaxNumber: | 4017376152 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 CENTERVILLE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028864376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017374581 | ||||||||
| FaxNumber: | 4017376152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225100000X | PT02008 | RI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 29806-7 | 01 | RI | BLUE CROSS | OTHER | 27877 | 01 | RI | NEIGHBORHOOD HEALTH | OTHER | 413078 | 01 | RI | BLUE CHIP | OTHER |