Provider Demographics
NPI:1003823956
Name:BASS, CRAIG B (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:B
Last Name:BASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 BOBWHITE CT
Mailing Address - Street 2:# 275
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6643
Mailing Address - Country:US
Mailing Address - Phone:208-333-0200
Mailing Address - Fax:208-333-0399
Practice Address - Street 1:250 BOBWHITE CT
Practice Address - Street 2:# 275
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6643
Practice Address - Country:US
Practice Address - Phone:208-333-0200
Practice Address - Fax:208-333-0399
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-43062086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC36896Medicare UPIN
ID1114695Medicare ID - Type UnspecifiedCURRENT MEDICARE