Healthcare Provider Details

I. General information

NPI: 1376617274
Provider Name (Legal Business Name): BRIAN E. BASHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E BRADFORD PKWY
SPRINGFIELD MO
65804-4264
US

IV. Provider business mailing address

1059 BARTON DR
FORDLAND MO
65652-7350
US

V. Phone/Fax

Practice location:
  • Phone: 417-767-2273
  • Fax:
Mailing address:
  • Phone: 417-767-2273
  • Fax: 417-767-4054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR7P13
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: