Healthcare Provider Details

I. General information

NPI: 1205365475
Provider Name (Legal Business Name): NISHCHAYJIT S BASRA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 17TH ST
COLUMBUS IN
47201-5351
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-376-5974
  • Fax: 812-375-3203
Mailing address:
  • Phone: 812-375-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2017017604
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02005927A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number02005927A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: