Healthcare Provider Details

I. General information

NPI: 1023907987
Provider Name (Legal Business Name): ROBERT BASEDOW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 E MAIN ST
PATCHOGUE NY
11772-3121
US

IV. Provider business mailing address

475 E MAIN ST
PATCHOGUE NY
11772-3121
US

V. Phone/Fax

Practice location:
  • Phone: 631-286-8282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: