Provider Demographics
NPI:1124206685
Name:BASIC, EDIN (DO)
Entity Type:Individual
Prefix:
First Name:EDIN
Middle Name:
Last Name:BASIC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45307 NORTHPORT DR
Mailing Address - Street 2:#3301
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15855 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:586-263-2950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017539207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine