Healthcare Provider Details

I. General information

NPI: 1437312758
Provider Name (Legal Business Name): BASHAR ERICSOOSSI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E DAY RD STE 300
MISHAWAKA IN
46545-3471
US

IV. Provider business mailing address

40 VALLEY STREAM PKWY STE 100
MALVERN PA
19355-1407
US

V. Phone/Fax

Practice location:
  • Phone: 574-968-0283
  • Fax: 574-968-0882
Mailing address:
  • Phone: 610-644-8900
  • Fax: 484-924-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number274622
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01089928A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: