Provider Demographics
NPI:1508870668
Name:BASS, ANDORA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDORA
Middle Name:
Last Name:BASS
Suffix:
Gender:F
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-8190
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-8190
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00547207L00000X, 207R00000X, 208000000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904203Medicaid
NC2054544AMedicare PIN