Provider Demographics
NPI:1558368019
Name:BAST, WILLIAM R (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:BAST
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 1:100 PENN ST
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-1956
Mailing Address - Country:US
Mailing Address - Phone:717-632-3220
Mailing Address - Fax:717-632-3220
Practice Address - Street 1:100 PENN ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-1956
Practice Address - Country:US
Practice Address - Phone:717-632-3220
Practice Address - Fax:717-632-3220
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 015215 E208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA158603X9SOtherMEDICARE PTAN
158603Medicare ID - Type Unspecified
PA158603X9SOtherMEDICARE PTAN