Healthcare Provider Details

I. General information

NPI: 1629381116
Provider Name (Legal Business Name): BASEL EDRIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 23RD ST STE 230
ASHLAND KY
41101-2868
US

IV. Provider business mailing address

PO BOX 2379
ASHLAND KY
41105-2379
US

V. Phone/Fax

Practice location:
  • Phone: 606-324-4745
  • Fax:
Mailing address:
  • Phone: 606-408-9571
  • Fax: 606-408-6061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number46448
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number46448
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number46448
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: