Provider Demographics
NPI:1700087632
Name:ERICSOUSSI, BASSEL (MD)
Entity Type:Individual
Prefix:DR
First Name:BASSEL
Middle Name:
Last Name:ERICSOUSSI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BASSEL
Other - Middle Name:
Other - Last Name:ERICSOUSSI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:761 45TH ST STE 108
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2899
Practice Address - Country:US
Practice Address - Phone:219-922-5416
Practice Address - Fax:219-922-3745
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069620A207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201063870Medicaid
INM47140090OtherMEDICARE PTAN