Provider Demographics
NPI:1265971063
Name:BASS MEDICAL GROUP
Entity type:Organization
Organization Name:BASS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RAJIV
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGESETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-932-6330
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:
Practice Address - Street 1:108 LA CASA VIA
Practice Address - Street 2:SUITE 100
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3013
Practice Address - Country:US
Practice Address - Phone:925-930-9120
Practice Address - Fax:925-930-9122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7360010013OtherNSC MEDICARE