Provider Demographics
NPI:1407825870
Name:BASS, CHARLES M (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:BASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:M
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-5375
Mailing Address - Fax:952-595-6455
Practice Address - Street 1:5100 GAMBLE DR SUITE 100 - MAIL STOP 31200A
Practice Address - Street 2:HEALTHPARTNERS WEST CLINIC
Practice Address - City:ST. LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1582
Practice Address - Country:US
Practice Address - Phone:952-541-2500
Practice Address - Fax:952-595-6455
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29729207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN569580500Medicaid
D98158Medicare UPIN
MN569580500Medicaid