Healthcare Provider Details

I. General information

NPI: 1689840787
Provider Name (Legal Business Name): LEWIS BASS DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 50 CATALPA AVE
RIDGEWOOD NY
11385-5032
US

IV. Provider business mailing address

31 PEACOCK DR
ROSLYN NY
11576-2522
US

V. Phone/Fax

Practice location:
  • Phone: 718-821-1969
  • Fax: 718-821-1125
Mailing address:
  • Phone: 516-625-1944
  • Fax: 516-626-6680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number124814
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number124814
License Number StateNY

VIII. Authorized Official

Name: DR. LEWIS BASS
Title or Position: PRESIDENT
Credential: MD
Phone: 516-625-1944