MEDICARE: DR. JACQUELINE KHRISTEN BASHAM 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	207V00000X	Obstetrics & Gynecology Physician	30475	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000204606	OTHER	KY	ANTHEM
2	000000204621	OTHER	KY	ANTHEM
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396709671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE KHRISTEN BASHAM MD

Provider Business Mailing Address
First Line	:	PO BOX 950248
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40295-0248
Country	:	US
Telephone Number	:	502-253-1035
Fax Number	:	502-253-1037

Provider Business Practice Location Address
First Line	:	140 STONECREST RD
Second Line	:
City	:	SHELBYVILLE
State	:	KY
Zip	:	40065-8142
Country	:	US
Telephone Number	:	502-633-0094
Fax Number	:	502-633-0033

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	08/21/2014

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