=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003053075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL A. BASCO M.D. PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2009
-----------------------------------------------------
Last Update Date | 08/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1903 DOCTORS HOSPITAL DR SUITE 36
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76426-2269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-683-0127
-----------------------------------------------------
Fax | 940-683-2270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1903 DOCTORS HOSPITAL DR SUITE 36
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76426-2269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-683-0127
-----------------------------------------------------
Fax | 940-683-2270
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL ANGELO BASCO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 940-683-0127
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | H5151
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------