Basic Information
| Provider Information | |||||||||
| NPI: | 1316907009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASHAM | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173556780 | ||||||||
| FaxNumber: | 3173559027 | ||||||||
| Practice Location | |||||||||
| Address1: | 9015 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462292016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173557700 | ||||||||
| FaxNumber: | 3173559027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01060886A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200826660 | 05 | IN | MEDICAID | 7372817 | 01 | IN | AETNA PIN # | OTHER | 000000485636 | 01 | IN | ANTHEM PIN # | OTHER | P00458712 | 01 | IN | MEDICARE RAILROAD # | OTHER | P01014119 | 01 | IN | RR MEDICARE PTAN | OTHER | 200311740A | 01 | IN | MEDICAID GROUP # | OTHER |