Healthcare Provider Details

I. General information

NPI: 1205811262
Provider Name (Legal Business Name): EDWARD KING BASS III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 W FRANKLIN ST
SYLVESTER GA
31791-1978
US

IV. Provider business mailing address

PO BOX 561
SYLVESTER GA
31791-0561
US

V. Phone/Fax

Practice location:
  • Phone: 229-776-2965
  • Fax: 229-776-4452
Mailing address:
  • Phone: 229-776-2965
  • Fax: 229-776-4452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number049270
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: