Provider Demographics
NPI:1275530560
Name:BASSAL, ALY A (MD, FICS)
Entity Type:Individual
Prefix:DR
First Name:ALY
Middle Name:A
Last Name:BASSAL
Suffix:
Gender:M
Credentials:MD, FICS
Other - Prefix:DR
Other - First Name:ALY
Other - Middle Name:A
Other - Last Name:BASSAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:1000 WEST G STREET SUITE 104
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37644-0640
Mailing Address - Country:US
Mailing Address - Phone:423-543-4616
Mailing Address - Fax:423-543-7771
Practice Address - Street 1:1000 W G ST
Practice Address - Street 2:SUITE 104
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2959
Practice Address - Country:US
Practice Address - Phone:423-543-4616
Practice Address - Fax:423-543-7771
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000013983207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3191532Medicaid
B04473Medicare UPIN
TN3191532Medicaid