Provider Demographics
NPI:1124407341
Name:BASHAM CLINIC, P.A.
Entity Type:Organization
Organization Name:BASHAM CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BASHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-750-0099
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-0063
Mailing Address - Country:US
Mailing Address - Phone:316-633-4413
Mailing Address - Fax:877-381-0101
Practice Address - Street 1:100 E 16TH ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:KS
Practice Address - Zip Code:67045-1067
Practice Address - Country:US
Practice Address - Phone:620-750-0099
Practice Address - Fax:620-583-6397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-28069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty