Provider Demographics
NPI:1508957200
Name:BASSALY, EMAD ROSHDY (MD)
Entity Type:Individual
Prefix:
First Name:EMAD
Middle Name:ROSHDY
Last Name:BASSALY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EMAD
Other - Middle Name:R
Other - Last Name:BASSALY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD PC
Mailing Address - Street 1:197 CHURCH POND DRIVE
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878
Mailing Address - Country:US
Mailing Address - Phone:401-624-1997
Mailing Address - Fax:401-624-7920
Practice Address - Street 1:1725 MENDON RD
Practice Address - Street 2:SUITE 203
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-4337
Practice Address - Country:US
Practice Address - Phone:401-333-6100
Practice Address - Fax:401-333-6109
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10521207LP2900X
MA46332207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0138967Medicaid
MA110003241AMedicaid
MAK08349Medicare PIN
A59651Medicare UPIN
MA110003241AMedicaid