Provider Demographics
NPI:1407856966
Name:EDWARD BASS MD PA
Entity Type:Organization
Organization Name:EDWARD BASS MD PA
Other - Org Name:BASS & LIPENKO MD PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN/NEUROLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-878-2800
Mailing Address - Street 1:4710 N HABANA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7161
Mailing Address - Country:US
Mailing Address - Phone:813-878-2800
Mailing Address - Fax:813-875-5213
Practice Address - Street 1:4710 N HABANA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7161
Practice Address - Country:US
Practice Address - Phone:813-878-2800
Practice Address - Fax:813-875-5213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLS931869412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266696100Medicaid
DA1412OtherRAILROAD MEDICARE
FL266696100Medicaid