Provider Demographics
NPI:1144222787
Name:BASS, BRIAN EDMOND (MD)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:EDMOND
Last Name:BASS
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 1:3805 COMPUTER DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6503
Mailing Address - Country:US
Mailing Address - Phone:919-781-6200
Mailing Address - Fax:919-783-1819
Practice Address - Street 1:3805 COMPUTER DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6503
Practice Address - Country:US
Practice Address - Phone:919-781-6200
Practice Address - Fax:919-783-1819
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36649207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8913868Medicaid
F63220Medicare UPIN
NC8913868Medicaid