Provider Demographics
NPI:1306385950
Name:BASIS INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:BASIS INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAZARTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-253-6329
Mailing Address - Street 1:1036 E IRON EAGLE DR STE 107
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6558
Mailing Address - Country:US
Mailing Address - Phone:208-789-2131
Mailing Address - Fax:866-950-0277
Practice Address - Street 1:1036 E IRON EAGLE DR STE 107
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6558
Practice Address - Country:US
Practice Address - Phone:208-789-2131
Practice Address - Fax:866-950-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-15
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM11082207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty