Healthcare Provider Details

I. General information

NPI: 1467198630
Provider Name (Legal Business Name): EMMANUEL PIERROT BASSIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 06/14/2025
Certification Date: 06/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N. EAST AVENUE
JACKSON MI
49201
US

IV. Provider business mailing address

1215 LEE ST BOX 800133
CHARLOTTESVILLE VA
22908-0816
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-7147
  • Fax:
Mailing address:
  • Phone: 434-924-1984
  • Fax: 434-244-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116040561
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: