MEDICARE: DR. CLAYTON A BASS MD

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	045167	GA
2	207P00000X	Emergency Medicine Physician	6068769-1205	UT
3	207P00000X	Emergency Medicine Physician	13154	MS

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	52755548-002	OTHER	GA	BCBS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1972598506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLAYTON A BASS MD

Provider Business Mailing Address
First Line	:	370 E SOUTH TEMPLE STE 260
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1290
Country	:	US
Telephone Number	:	801-463-7415
Fax Number	:	801-463-7341

Provider Business Practice Location Address
First Line	:	5475 S 500 E
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84405-6905
Country	:	US
Telephone Number	:	801-463-7415
Fax Number	:	801-463-7341

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	07/09/2009

5475 S 500 E FL 1
OGDEN, UT
84405-6905

Practice Phone: 801-479-2111
Practice Fax: