MEDICARE: SHERMAN KEVIN BASONG PT, DPT

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	225100000X	Physical Therapist	PTLICENSE2637	SC

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	:	1639187487
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERMAN KEVIN BASONG PT, DPT

Provider Business Mailing Address
First Line	:	220 ROPER MOUNTAIN ROAD EXT
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-4886
Country	:	US
Telephone Number	:	864-242-1163
Fax Number	:	864-242-1167

Provider Business Practice Location Address
First Line	:	10 ENTERPRISE BLVD
Second Line	:	STE 201
City	:	GREENVILLE
State	:	SC
Zip	:	29615-3554
Country	:	US
Telephone Number	:	864-583-0053
Fax Number	:

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

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	10/11/2019

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