Provider Demographics
NPI:1841381027
Name:RADISIC-BASOVIC, MARINA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARINA
Middle Name:
Last Name:RADISIC-BASOVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 NANCY ROAD
Mailing Address - Street 2:#8
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375
Mailing Address - Country:US
Mailing Address - Phone:508-230-0395
Mailing Address - Fax:
Practice Address - Street 1:1061 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740
Practice Address - Country:US
Practice Address - Phone:508-984-5566
Practice Address - Fax:508-994-5527
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2229972084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
I34794Medicare UPIN
A38781Medicare ID - Type Unspecified