Provider Demographics
NPI:1740527357
Name:BASAVAIAH, THARA (MD)
Entity type:Individual
Prefix:
First Name:THARA
Middle Name:
Last Name:BASAVAIAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 INDUSTRIAL RD
Mailing Address - Street 2:STE 5
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-3736
Mailing Address - Country:US
Mailing Address - Phone:508-473-1480
Mailing Address - Fax:508-473-1210
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-374-7700
Practice Address - Fax:740-374-7701
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.121464207R00000X, 208M00000X
MA266249207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP10248544OtherRAILROAD MEDICARE - MHCPI
WV3810026377Medicaid
OH0086280Medicaid
WV3810026377Medicaid