Provider Demographics
NPI:1952661928
Name:BASEDOW, ROBERT O JR (RN)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:O
Last Name:BASEDOW
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2226 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7100
Mailing Address - Country:US
Mailing Address - Phone:631-676-6682
Mailing Address - Fax:
Practice Address - Street 1:2226 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7100
Practice Address - Country:US
Practice Address - Phone:631-676-6682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY633543163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse