MEDICARE: NADIJDA TANNOUS BASSIL 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	036144058	IL
2	207Q00000X	Family Medicine Physician	ME124206	FL

General Provider Information

NPI Number	:	1730445743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NADIJDA TANNOUS BASSIL M.D.

Provider Business Mailing Address
First Line	:	1255 S MICHIGAN AVE APT 2505
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-3312
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6918 GUNN HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33625-3853
Country	:	US
Telephone Number	:	813-891-6310
Fax Number	:	813-891-6889

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

Provider Enumeration Date	:	04/03/2012
Last Update Date	:	06/12/2019

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