Basic Information
| Provider Information | |||||||||
| NPI: | 1710944707 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASSIL | ||||||||
| FirstName: | HABIB | ||||||||
| MiddleName: | FOUAD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4402 BRENTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245922955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345721381 | ||||||||
| FaxNumber: | 4345721381 | ||||||||
| Practice Location | |||||||||
| Address1: | 2232 WILBORN AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345728977 | ||||||||
| FaxNumber: | 4345722510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 09/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 0101044555 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 005879817 | 05 | VA | MEDICAID |