Basic Information
| Provider Information | |||||||||
| NPI: | 1336179910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 HIGHWAY 59 S | ||||||||
| Address2: | |||||||||
| City: | THIEF RIVER FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567014331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186814747 | ||||||||
| FaxNumber: | 2186832595 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 HIGHWAY 59 S | ||||||||
| Address2: | |||||||||
| City: | THIEF RIVER FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567014331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186814747 | ||||||||
| FaxNumber: | 2186832595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 43101 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 73Q72BA | 01 | MN | MNBS # | OTHER | 0701567 | 01 | MN | MEDICA # | OTHER | ND200210 | 01 | MN | LHS # | OTHER | HP38654 | 01 | MN | HEALTHPARTNERS # | OTHER | 141993 | 01 | MN | UCARE # | OTHER | 1172372 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | 12150 | 05 | MN | MEDICAID | 20477 | 01 | MN | NDBS # | OTHER | 5041522000 | 05 | MN | MEDICAID | DA9021026958 | 01 | MN | PREFERRED ONE # | OTHER |