Healthcare Provider Details

I. General information

NPI: 1336343938
Provider Name (Legal Business Name): MICHAEL J BASS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 FOUNTAIN COURT SUITE 160
LEXINGTON KY
40509
US

IV. Provider business mailing address

216 FOUNTAIN COURT SUITE 160
LEXINGTON KY
40509
US

V. Phone/Fax

Practice location:
  • Phone: 859-543-1024
  • Fax: 859-543-0141
Mailing address:
  • Phone: 859-543-1024
  • Fax: 859-543-0141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberBP1-0016836
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number40717
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: