Provider Demographics
NPI:1275835845
Name:BASHA, IMAD SHAMSI (MD)
Entity Type:Individual
Prefix:DR
First Name:IMAD
Middle Name:SHAMSI
Last Name:BASHA
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 1:9001 N MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1154
Mailing Address - Country:US
Mailing Address - Phone:937-832-0990
Mailing Address - Fax:937-832-7323
Practice Address - Street 1:9001 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1154
Practice Address - Country:US
Practice Address - Phone:937-832-0990
Practice Address - Fax:937-832-7323
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075324207RC0200X
OH35.065103207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2313820Medicaid
OHBA0751993Medicare PIN