Provider Demographics
NPI:1043329055
Name:BASSALI, REDA (MBCHB)
Entity Type:Individual
Prefix:
First Name:REDA
Middle Name:
Last Name:BASSALI
Suffix:
Gender:M
Credentials:MBCHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2602
Mailing Address - Country:US
Mailing Address - Phone:706-828-8402
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038682208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000619704AMedicaid
SCG38682Medicaid
GA37BBCVCMedicare ID - Type UnspecifiedGA MCARE
GA000619704AMedicaid