Provider Demographics
NPI:1073731592
Name:PAULUS, BASIL MANTAS (MD)
Entity Type:Individual
Prefix:DR
First Name:BASIL
Middle Name:MANTAS
Last Name:PAULUS
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 1:8060 WOLF RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1727
Mailing Address - Country:US
Mailing Address - Phone:901-271-1000
Mailing Address - Fax:901-271-4187
Practice Address - Street 1:8060 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1727
Practice Address - Country:US
Practice Address - Phone:901-271-1000
Practice Address - Fax:901-271-4187
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS43843207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I060446Medicare PIN