Provider Demographics
NPI:1073505525
Name:BASIL, JACK B (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:B
Last Name:BASIL
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:PO BOX 635063
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-891-1006
Mailing Address - Fax:
Practice Address - Street 1:3219 CLIFTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-3027
Practice Address - Country:US
Practice Address - Phone:513-862-1888
Practice Address - Fax:513-862-3616
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084002207VX0201X, 207VX0201X
KY38584207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64083140Medicaid
IN200215750Medicaid
OH2473256Medicaid
KY64083140Medicaid
KYP00140818Medicare PIN
H14595Medicare UPIN
IN200215750Medicaid
KY0655049Medicare PIN