Provider Demographics
NPI:1649646282
Name:BASS MEDICAL GROUP
Entity type:Organization
Organization Name:BASS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:INEZ
Authorized Official - Middle Name:
Authorized Official - Last Name:WONDEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-378-4512
Mailing Address - Street 1:2637 SHADELANDS DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2512
Mailing Address - Country:US
Mailing Address - Phone:925-948-8143
Mailing Address - Fax:925-215-4540
Practice Address - Street 1:5924 STONERIDGE DR STE 202
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-5400
Practice Address - Country:US
Practice Address - Phone:925-600-7020
Practice Address - Fax:925-600-7010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619916293OtherINDIVIDUAL NPI
736010002OtherNSC MEDICARE