Provider Demographics
NPI:1417041666
Name:BASH, STEPHEN E (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:E
Last Name:BASH
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 1:6161 N TRAILS END
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-3524
Mailing Address - Country:US
Mailing Address - Phone:309-692-2664
Mailing Address - Fax:309-692-2664
Practice Address - Street 1:6161 N TRAILS END
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3524
Practice Address - Country:US
Practice Address - Phone:309-692-2664
Practice Address - Fax:309-692-2664
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0706942080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036070694Medicaid
L64781Medicare ID - Type Unspecified
IL036070694Medicaid
ILIL3270112Medicare PIN
208905086Medicare PIN