Basic Information
| Provider Information | |||||||||
| NPI: | 1164788774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASFORD | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | BRYAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1108 ROSS CLARK CIR | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1108 ROSS CLARK CIR | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2012 | ||||||||
| LastUpdateDate: | 01/22/2019 | ||||||||
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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 | 207P00000X | 36180 | AL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.