Provider Demographics
NPI:1336130079
Name:BASS, JAMES JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:JEFFREY
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 1:1050 W 10TH ST
Mailing Address - Street 2:ATTN: EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4900
Mailing Address - Country:US
Mailing Address - Phone:573-364-9000
Mailing Address - Fax:573-368-4422
Practice Address - Street 1:1201 HAUCK DR
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4900
Practice Address - Country:US
Practice Address - Phone:573-364-8818
Practice Address - Fax:573-368-4422
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2C49208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO100719OtherHEALTHLINK
MO010066255OtherRAILROAD MEDICARE
MO9476OtherBLUE CROSS BLUE SHIELD
MO201810504Medicaid
MO26D0446816OtherCLIA LABORATORY CERTIFICA
MO9476OtherBLUE CROSS BLUE SHIELD
MO010066255OtherRAILROAD MEDICARE