Healthcare Provider Details

I. General information

NPI: 1831283456
Provider Name (Legal Business Name): BASSEL BARDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 RYANS RD
WORTHINGTON MN
56187-1722
US

IV. Provider business mailing address

1216 RYANS RD
WORTHINGTON MN
56187-1722
US

V. Phone/Fax

Practice location:
  • Phone: 507-372-2921
  • Fax: 507-372-5789
Mailing address:
  • Phone: 507-372-2921
  • Fax: 507-372-5789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number39465
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: