Provider Demographics
NPI:1124515838
Name:ADDO, BASILIO NII AYITEY (MD)
Entity type:Individual
Prefix:MR
First Name:BASILIO
Middle Name:NII AYITEY
Last Name:ADDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 117264
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-7264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1270 PRINCE AVE STE 201
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2789
Practice Address - Country:US
Practice Address - Phone:706-475-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2021-07-15
Deactivation Date:2018-11-28
Deactivation Code:
Reactivation Date:2019-07-08
Provider Licenses
StateLicense IDTaxonomies
GA88806208M00000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program