Healthcare Provider Details

I. General information

NPI: 1982687521
Provider Name (Legal Business Name): BASMAN ABDEL SALOUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 05/01/2023
Certification Date: 04/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6913 N MAIN ST STE 300
GRANGER IN
46530-8039
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1500
  • Fax: 574-243-4310
Mailing address:
  • Phone: 574-647-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01043104A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: