Basic Information
| Provider Information | |||||||||
| NPI: | 1497983084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASALY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 W PINELOCH AVE STE 23 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328066100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074817179 | ||||||||
| FaxNumber: | 4074817190 | ||||||||
| Practice Location | |||||||||
| Address1: | 86 W UNDERWOOD ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889123648 | ||||||||
| FaxNumber: | 3218414085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2009 | ||||||||
| LastUpdateDate: | 12/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | LL31891 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 2016-02367 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | ME124898 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 2016-02367 | NC | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | ME124898 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 318917 | 05 | SC | MEDICAID | 016490700 | 05 | FL | MEDICAID | RHC202 | 05 | SC | MEDICAID | GP4819 | 05 | SC | MEDICAID |