Basic Information
| Provider Information | |||||||||
| NPI: | 1154401941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BASS MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BAY AREA SURGICAL SPECIALISTS INC A MEDICAL CORPORATION | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2637 SHADELANDS DR | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259326330 | ||||||||
| FaxNumber: | 9259320139 | ||||||||
| Practice Location | |||||||||
| Address1: | 2637 SHADELANDS DR | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259326330 | ||||||||
| FaxNumber: | 9259320139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RHODES | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9257881440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A71377 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | A77948 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | G32920 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | A78168 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | G54054 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | A43945 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1208539636 | 01 | CA | NPI | OTHER | 1285638015 | 01 | CA | NPI | OTHER | 1477655363 | 01 | CA | NPI | OTHER | 1689786840 | 01 | CA | NPI | OTHER | 1750347100 | 01 | CA | NPI | OTHER | 1508803172 | 01 | CA | NPI | OTHER | 1346244183 | 01 | CA | NPI | OTHER | 1467554337 | 01 | CA | NPI | OTHER |