Provider Demographics
NPI:1245260850
Name:BASESKI, THERESA MARY (DO)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:MARY
Last Name:BASESKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:705-790-2391
Mailing Address - Fax:
Practice Address - Street 1:1000 ALLIANCE DR STE 10
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-3234
Practice Address - Country:US
Practice Address - Phone:570-501-6450
Practice Address - Fax:570-501-6436
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007866L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015282730014Medicaid
PA0015282730006Medicaid
PA776416YGDBMedicare PIN
PA123397Medicare ID - Type Unspecified