Healthcare Provider Details

I. General information

NPI: 1669507273
Provider Name (Legal Business Name): TSILYA BASS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N FAIRFAX AVE STE 109
WEST HOLLYWOOD CA
90046-5363
US

IV. Provider business mailing address

1111 N FAIRFAX AVE STE 109
WEST HOLLYWOOD CA
90046-5363
US

V. Phone/Fax

Practice location:
  • Phone: 323-876-1500
  • Fax: 323-876-1515
Mailing address:
  • Phone: 323-876-1500
  • Fax: 323-876-1515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA63630
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA63630
License Number StateCA

VIII. Authorized Official

Name: TSILYA BASS
Title or Position: PHISICIAN
Credential: M.D.
Phone: 323-876-1500