Provider Demographics
NPI:1487751962
Name:BASS, MICHAEL PERRY (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PERRY
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 1:515 MICHIGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-2705
Mailing Address - Country:US
Mailing Address - Phone:916-368-0816
Mailing Address - Fax:916-469-2273
Practice Address - Street 1:515 MICHIGAN BLVD
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-2705
Practice Address - Country:US
Practice Address - Phone:916-368-0816
Practice Address - Fax:916-469-2273
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32503173000000X, 208D00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No173000000XOther Service ProvidersLegal Medicine
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGROUP'S PTAN HJ036AOtherGROUP'S PTAN HJ036A
CAZZZ03418ZMedicare ID - Type UnspecifiedGROUP MEDICARE ID NUMBER
CAPTAN FJ658YMedicare PIN