Basic Information
| Provider Information | |||||||||
| NPI: | 1477889624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASCO | ||||||||
| FirstName: | WILLIE | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | MARCUS HOOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190614513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108598850 | ||||||||
| FaxNumber: | 6108597876 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 DEAK DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SMYRNA | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199771268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026595700 | ||||||||
| FaxNumber: | 3026595703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2009 | ||||||||
| LastUpdateDate: | 06/18/2010 | ||||||||
| 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 | 225100000X | J10002517 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000020536 | 01 | DE | DPCI | OTHER | 1477889624 | 05 | DE | MEDICAID | 3768331000 | 01 | DE | IBC | OTHER |