Provider Demographics
NPI:1376603985
Name:BASILIERE, JAMES L (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:L
Last Name:BASILIERE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1300 SOUTH DR.
Mailing Address - Street 2:WINNEBAGO MENTAL HEALTH INSTITUTE
Mailing Address - City:WINNEBAGO
Mailing Address - State:WI
Mailing Address - Zip Code:54985-0009
Mailing Address - Country:US
Mailing Address - Phone:920-235-4910
Mailing Address - Fax:920-236-2931
Practice Address - Street 1:1300 SOUTH DR.
Practice Address - Street 2:WINNEBAGO MENTAL HEALTH INSTITUTE
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-0009
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:920-236-2931
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
WI14738207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31240600Medicaid
WI31240600Medicaid
WIB84672Medicare UPIN