Provider Demographics
NPI:1528011640
Name:LEDESMA, BASILIO (MD)
Entity Type:Individual
Prefix:
First Name:BASILIO
Middle Name:
Last Name:LEDESMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3114 CROASDAILE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2508
Mailing Address - Country:US
Mailing Address - Phone:919-425-1565
Mailing Address - Fax:919-425-0478
Practice Address - Street 1:72 S STATE ST
Practice Address - Street 2:EMERGENCY MEDICINE
Practice Address - City:SHELBY
Practice Address - State:MI
Practice Address - Zip Code:49455-1228
Practice Address - Country:US
Practice Address - Phone:919-425-1565
Practice Address - Fax:919-425-0478
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301037909207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104263805Medicaid
MI104968130Medicaid
MIBL037909OtherBLUE CROSS
MIB44655Medicare UPIN
MIP08500003Medicare ID - Type Unspecified
MIP38120003Medicare PIN