MEDICARE: DR. JOHN W BASORE III MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	3663	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51000276	OTHER	AL	BCBS

General Provider Information

NPI Number	:	1134220056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN W BASORE III MD

Provider Business Mailing Address
First Line	:	2227 DRAKE AVE
Second Line	:	SUITE 7A
City	:	HUNTSVILLE
State	:	AL
Zip	:	35805-5199
Country	:	US
Telephone Number	:	256-883-5600
Fax Number	:	256-883-5604

Provider Business Practice Location Address
First Line	:	2227 DRAKE AVE
Second Line	:	SUITE 7A
City	:	HUNTSVILLE
State	:	AL
Zip	:	35805-5199
Country	:	US
Telephone Number	:	256-883-5600
Fax Number	:	256-883-5604

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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