Provider Demographics
NPI:1174572382
Name:BASS, WILLIAM THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:THOMAS
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 79137
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0137
Mailing Address - Country:US
Mailing Address - Phone:757-668-7200
Mailing Address - Fax:757-668-9691
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-7456
Practice Address - Fax:757-668-9255
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010412372080N0001X, 208000000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9801055000Medicaid
NC890501GMedicaid
DE0000937601Medicaid
MD120431900Medicaid
PA0018724740001Medicaid
VA006722172Medicaid
MD120431900Medicaid
VA370000935Medicare ID - Type Unspecified