Basic Information
| Provider Information | |||||||||
| NPI: | 1841511441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASALY | ||||||||
| FirstName: | ELMIRA | ||||||||
| MiddleName: | SADEGHI RAZLIGHI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 CENTURY MEDICAL DR OFC | ||||||||
| Address2: | |||||||||
| City: | TITUSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327962100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212686111 | ||||||||
| FaxNumber: | 3212686360 | ||||||||
| Practice Location | |||||||||
| Address1: | 951 N WASHINGTON AVE | ||||||||
| Address2: | HOSPITALIST DEPT. | ||||||||
| City: | TITUSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212686111 | ||||||||
| FaxNumber: | 3212686360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2010 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | LL32557 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2016-01587 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 2016-01587 | NC | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 80718 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | ME125020 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 43058500 | 05 | WI | MEDICAID | 016526300 | 05 | FL | MEDICAID |