Provider Demographics
NPI:1366731648
Name:BASQUE, CHRISTIAN (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:
Last Name:BASQUE
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 820933
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-926-9010
Mailing Address - Fax:215-226-8285
Practice Address - Street 1:46 BARRA RD STE 103
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9461
Practice Address - Country:US
Practice Address - Phone:207-283-1126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD453023207Q00000X
MEMD21013207RS0010X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACD4829OtherTPI GROUP RAILROAD MEDICARE
PA597586OtherTPI GROUP MEDICARE
PA100727800OtherTPI GROUP PA MAID