Healthcare Provider Details

I. General information

NPI: 1538391446
Provider Name (Legal Business Name): INDRANILL BASU RAY MD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 PARK AVE STE 825B
MEMPHIS TN
38119-5223
US

IV. Provider business mailing address

1755 GROVEWAY DR
GERMANTOWN TN
38139-5554
US

V. Phone/Fax

Practice location:
  • Phone: 617-308-0580
  • Fax:
Mailing address:
  • Phone: 617-308-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number57891
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number57891
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: