Basic Information
| Provider Information | |||||||||
| NPI: | 1316520034 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BASS MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2637 SHADELANDS DR | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259488143 | ||||||||
| FaxNumber: | 9252154540 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 LENNON LN | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259488143 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2021 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9259488143 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 207RX0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
No ID Information.