Provider Demographics
NPI:1245233857
Name:BASSETT, PERRY E (MD)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:E
Last Name:BASSETT
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 1:4201 N SONCY RD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79124-5724
Mailing Address - Country:US
Mailing Address - Phone:806-231-4946
Mailing Address - Fax:806-677-0018
Practice Address - Street 1:4201 N SONCY RD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79124-5724
Practice Address - Country:US
Practice Address - Phone:806-231-4946
Practice Address - Fax:806-677-0018
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1159207Q00000X, 207P00000X
OK24393207P00000X
KST01995207P00000X
WV23559207P00000X
MO2009012111207P00000X
IA38632207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1245233857Medicaid
KS200575060AMedicaid
MO1245233857Medicaid
OK200069550AMedicaid
KY7100144460Medicaid
VA1245233857Medicaid
OH4315971Medicaid
TX133605913Medicaid
KS200575060EMedicaid
WV3810016569Medicaid
NE10025874900Medicaid
TX133605909Medicaid
TN1521898Medicaid
OH4315972Medicaid
OH4315971Medicaid
TX133605913Medicaid
IA1245233857Medicaid
OKOK400318Medicare PIN
IL206813013Medicare PIN
G33867Medicare UPIN
KY7100144460Medicaid
WV3810016569Medicaid
VA1245233857Medicaid
KSKA1000014Medicare PIN
WVBA4266352Medicare PIN
TX8008B7Medicare ID - Type UnspecifiedTRAILBLAZER HEALTH ENTERP
WVBA4266351Medicare PIN