Provider Demographics
NPI:1255418885
Name:BASELLI, EDGAR C (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:C
Last Name:BASELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 FREEDOM WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402
Mailing Address - Country:US
Mailing Address - Phone:717-741-9536
Mailing Address - Fax:717-741-5509
Practice Address - Street 1:2350 FREEDOM WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402
Practice Address - Country:US
Practice Address - Phone:717-741-9536
Practice Address - Fax:717-741-5509
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD068011L174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02208001OtherCAPITAL BLUECROSS
PA0018496900004Medicaid
PA664700OtherHIGHMARK BLUESHIELD
PA0018496900004Medicaid
PA664700OtherHIGHMARK BLUESHIELD