Provider Demographics
NPI:1164468583
Name:BASS, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
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:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE STREET SE, MMC 94
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-2755
Mailing Address - Fax:612-626-2467
Practice Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - Street 2:516 DELAWARE STREET SE, PWB FOURTH FLOOR, ROOM 4-100
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-672-7122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24910208000000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1984401Medicaid
WI30259200Medicaid
MT0055641Medicaid
MN276893300Medicaid
RIJB40370Medicaid
MN604547OtherARAZ
ID805361700Medicaid
MNHP12862OtherHEALTHPARTNERS
MN2570708OtherMEDICA PRIMARY
MN2T119BAOtherBCBS
MN101002OtherUCARE
MN0644007OtherPREFERRED ONE
ND10383Medicaid
MN25-22585OtherMEDICA CHOICE
MN2570708OtherMEDICA PRIMARY
ID805361700Medicaid
MT0055641Medicaid
RIJB40370Medicaid