Provider Demographics
NPI:1598717951
Name:BASS, R BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:R
Middle Name:BRUCE
Last Name:BASS
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:PO BOX 277827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 DOCTORS PARK DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1008
Practice Address - Country:US
Practice Address - Phone:864-585-2587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14747208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00402263OtherMEDICARE RAILROAD PTAN#
SC147479Medicaid
SC5878670015Medicare NSC
SCC675257571Medicare PIN
SCP00402263OtherMEDICARE RAILROAD PTAN#
C67525Medicare ID - Type Unspecified
SCC675258688Medicare PIN