Provider Demographics
NPI:1023143393
Name:BASILIO, FEODERIS N (MD)
Entity type:Individual
Prefix:
First Name:FEODERIS
Middle Name:N
Last Name:BASILIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FEODERIS
Other - Middle Name:BASILIO
Other - Last Name:SEBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:104 14TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2131
Mailing Address - Country:US
Mailing Address - Phone:706-507-5437
Mailing Address - Fax:706-507-5499
Practice Address - Street 1:104 14TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2131
Practice Address - Country:US
Practice Address - Phone:706-507-5437
Practice Address - Fax:706-507-5499
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0500922080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000958702AOtherPEACH STATE HEALTH PLAN
GA000958702AMedicaid
GA52009279OtherBCBS GA
GA306085OtherWELLCARE
AL60103339OtherBCBS AL