Provider Demographics
NPI:1356477616
Name:I BASILIO MD, PC
Entity Type:Organization
Organization Name:I BASILIO MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:FEODERIS
Authorized Official - Middle Name:N
Authorized Official - Last Name:BASILIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-507-5437
Mailing Address - Street 1:104 14TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2131
Mailing Address - Country:US
Mailing Address - Phone:706-507-5437
Mailing Address - Fax:
Practice Address - Street 1:2039 WARM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-7931
Practice Address - Country:US
Practice Address - Phone:706-576-5570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000958702CMedicaid