Provider Demographics
NPI:1356393680
Name:BASS, GEORGE LISTON (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:LISTON
Last Name:BASS
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:
Practice Address - Street 1:120 HEYWOOD AVE
Practice Address - Street 2:STE 200
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1210
Practice Address - Country:US
Practice Address - Phone:864-573-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4780207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00386910OtherRAILROAD MEDICARE PTAN#
SC47808Medicaid
GAP00386910OtherRAILROAD MEDICARE PTAN#
SCC606874722Medicare PIN
SC5286Medicare PIN
C60687Medicare UPIN
SC5878670017Medicare NSC
SC47808Medicaid