MEDICARE: DANA B BASS BURCH PA

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	363AM0700X	Medical Physician Assistant	1843	GA

General Provider Information

NPI Number	:	1992943195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANA B BASS BURCH PA

Provider Business Mailing Address
First Line	:	794 MCDONOUGH RD
Second Line	:	SUITE 111
City	:	JACKSON
State	:	GA
Zip	:	30233-1572
Country	:	US
Telephone Number	:	470-251-5300
Fax Number	:	470-251-5301

Provider Business Practice Location Address
First Line	:	794 MCDONOUGH RD
Second Line	:	SUITE 111
City	:	JACKSON
State	:	GA
Zip	:	30233-1572
Country	:	US
Telephone Number	:	470-251-5300
Fax Number	:	470-251-5301

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

Provider Enumeration Date	:	01/26/2009
Last Update Date	:	12/04/2016

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