MEDICARE: DR. MERVAT BASTA 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	207L00000X	Anesthesiology Physician	26169	AZ
2	282N00000X	General Acute Care Hospital	26169	AZ

General Provider Information

NPI Number	:	1285770115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MERVAT BASTA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 52650
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85208-0133
Country	:	US
Telephone Number	:	888-206-5902
Fax Number	:	480-466-7536

Provider Business Practice Location Address
First Line	:	4825 S HIGHWAY 95 # 2-356
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426
Country	:	US
Telephone Number	:	888-206-5902
Fax Number	:	480-466-7536

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	12/04/2020

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