Provider Demographics
NPI:1750310561
Name:BASILE, PHANEL (MD)
Entity Type:Individual
Prefix:
First Name:PHANEL
Middle Name:
Last Name:BASILE
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 636019
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 COMBS RD
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-1808
Practice Address - Country:US
Practice Address - Phone:276-546-1440
Practice Address - Fax:865-291-3228
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035989207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0125442OtherBC BS
VA1750310561Medicaid
VAP00209168OtherRAILROAD MEDICARE
TN3050025Medicaid
KY64796055Medicaid
TN3050025Medicaid
VA1750310561Medicaid
TN3050025Medicare PIN