Basic Information
| Provider Information | |||||||||
| NPI: | 1710087697 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HANY BASTA, M.D., PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 S LAKE AVE | ||||||||
| Address2: | 535 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911013005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267956596 | ||||||||
| FaxNumber: | 6267958247 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 W 3RD ST | ||||||||
| Address2: | 120 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900571932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2132075635 | ||||||||
| FaxNumber: | 2132075889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 02/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | BASTA | ||||||||
| AuthorizedOfficialFirstName: | HANY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6267956596 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A54439 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 6755130 | 01 | CA | PIN MEDI-CAL # | OTHER | 00A544390 | 05 | CA | MEDICAID |