Healthcare Provider Details

I. General information

NPI: 1073505525
Provider Name (Legal Business Name): JACK B BASIL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 CLIFTON AVE SUITE 100
CINCINNATI OH
45220-3027
US

IV. Provider business mailing address

PO BOX 635063
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 513-862-1888
  • Fax: 513-862-3616
Mailing address:
  • Phone: 513-891-1006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number35084002
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: