Healthcare Provider Details

I. General information

NPI: 1245260850
Provider Name (Legal Business Name): THERESA MARY BASESKI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ALLIANCE DR STE 10
HAZLETON PA
18202-3234
US

IV. Provider business mailing address

2100 MACK BLVD FL 4
ALLENTOWN PA
18103-5622
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-6450
  • Fax: 570-501-6436
Mailing address:
  • Phone: 705-790-2391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberOS007866L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0015282730014
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: