MEDICARE: DR. TARA KOPP BASTEK M.D.

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	208000000X	Pediatrics Physician	9900162	NC
2	2080N0001X	Neonatal-Perinatal Medicine Physician	9900162	NC

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	:	1316956774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TARA KOPP BASTEK M.D.

Provider Business Mailing Address
First Line	:	3024 NEW BERN AVE
Second Line	:	SUITE 300
City	:	RALEIGH
State	:	NC
Zip	:	27610-1247
Country	:	US
Telephone Number	:	919-350-8228
Fax Number	:	919-350-7976

Provider Business Practice Location Address
First Line	:	3000 NEW BERN AVE
Second Line	:	NEONATOLOGY DEPT.
City	:	RALEIGH
State	:	NC
Zip	:	27610-1231
Country	:	US
Telephone Number	:	919-350-8545
Fax Number	:	919-350-8146

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

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	03/12/2010

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