Healthcare Provider Details

I. General information

NPI: 1982977435
Provider Name (Legal Business Name): WILLIAM R BASTA MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SCHOOL ST SUITE 303
GLEN COVE NY
11542-2590
US

IV. Provider business mailing address

3 SCHOOL ST SUITE 303
GLEN COVE NY
11542-2590
US

V. Phone/Fax

Practice location:
  • Phone: 516-676-2878
  • Fax: 516-674-2256
Mailing address:
  • Phone: 516-676-2878
  • Fax: 516-674-2256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM BASTA
Title or Position: OWNER
Credential: M.D.
Phone: 516-676-2878