MEDICARE: DR. JAMES WILLIAM BASS III M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	K2844	TX
2	207Q00000X	Family Medicine Physician	31130	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8AG193	OTHER	TX	BCBS OF TEXAS
2	TIN PLUS 002	OTHER	TX	TRICARE LAKE PALESTINE LOCATION
3	514553	OTHER	TX	PHCS
4	TIN PLUS 029	OTHER	TX	TRICARE
5	75-2616977-001	OTHER	TX	TRICARE
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003878042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES WILLIAM BASS III M.D.

Provider Business Mailing Address
First Line	:	1800 W. 1ST ST.
Second Line	:	SUITE 102
City	:	ELK CITY
State	:	OK
Zip	:	73644-2339
Country	:	US
Telephone Number	:	580-225-2515
Fax Number	:	580-303-5850

Provider Business Practice Location Address
First Line	:	1800 W. 1ST ST.
Second Line	:	SUITE 102
City	:	ELK CITY
State	:	OK
Zip	:	73644-2339
Country	:	US
Telephone Number	:	580-225-2515
Fax Number	:	580-303-5850

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	03/10/2016

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