Basic Information
Provider Information | |||||||||
NPI: | 1225017635 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BASTA | ||||||||
FirstName: | NABIL | ||||||||
MiddleName: | N | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14275 MIDWAY RD | ||||||||
Address2: | SUITE 400 | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750013614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3172758000 | ||||||||
FaxNumber: | 6102714245 | ||||||||
Practice Location | |||||||||
Address1: | 1350 WALTON WAY | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309012612 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067745400 | ||||||||
FaxNumber: | 7067745096 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/13/2006 | ||||||||
LastUpdateDate: | 07/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 043544 | GA | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 299904569A | 05 | GA |   | MEDICAID | 5258684002 | 01 | GA | BCBS | OTHER | 337958 | 01 | GA | WELLCARE | OTHER | G43544 | 05 | SC |   | MEDICAID | 10058435 | 01 | GA | AMERIGROUP | OTHER | 58-146543-001 | 01 | GA | TRICARE | OTHER |