Provider Demographics
NPI:1922276419
Name:PHILIP A. BASALA, DO, LLC
Entity Type:Organization
Organization Name:PHILIP A. BASALA, DO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BASALA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:814-445-1096
Mailing Address - Street 1:792 N CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-1026
Mailing Address - Country:US
Mailing Address - Phone:814-445-1096
Mailing Address - Fax:814-445-8005
Practice Address - Street 1:792 N CENTER AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-1026
Practice Address - Country:US
Practice Address - Phone:814-445-1096
Practice Address - Fax:814-445-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007402E207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6775558Medicare PIN
PAE90635Medicare UPIN