Provider Demographics
NPI:1841234747
Name:BASS, SAMUAL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUAL
Middle Name:
Last Name:BASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-322-1680
Mailing Address - Fax:208-322-1695
Practice Address - Street 1:300 E JEFFERSON
Practice Address - Street 2:STE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-336-4141
Practice Address - Fax:208-336-4035
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ILM9570207RC0000X
IDM9570207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease