Provider Demographics
NPI:1760081756
Name:BASS, MARK A SR
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BASS
Suffix:SR
Gender:M
Credentials:
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 2204
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45401-2204
Mailing Address - Country:US
Mailing Address - Phone:313-657-3384
Mailing Address - Fax:614-987-8649
Practice Address - Street 1:2301 PHILADELPHIA DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1816
Practice Address - Country:US
Practice Address - Phone:313-657-3384
Practice Address - Fax:614-987-8649
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)