MEDICARE: DR. ALY A. BASSAL M.D., F.I.C.S.

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	MD0000013983	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275530560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALY A. BASSAL M.D., F.I.C.S.

Provider Business Mailing Address
First Line	:	PO BOX 640
Second Line	:	1000 WEST G STREET SUITE 104
City	:	ELIZABETHTON
State	:	TN
Zip	:	37644-0640
Country	:	US
Telephone Number	:	423-543-4616
Fax Number	:	423-543-7771

Provider Business Practice Location Address
First Line	:	1000 W G ST
Second Line	:	SUITE 104
City	:	ELIZABETHTON
State	:	TN
Zip	:	37643-2959
Country	:	US
Telephone Number	:	423-543-4616
Fax Number	:	423-543-7771

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

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	10/05/2012

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