Provider Demographics
NPI:1154539708
Name:BASKERVILLE, GARRICK MANSA (MD)
Entity type:Individual
Prefix:DR
First Name:GARRICK
Middle Name:MANSA
Last Name:BASKERVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 MACDADE BLVD
Mailing Address - Street 2:
Mailing Address - City:MILMONT PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19033-3311
Mailing Address - Country:US
Mailing Address - Phone:610-619-7300
Mailing Address - Fax:610-522-0445
Practice Address - Street 1:500 MACDADE BLVD
Practice Address - Street 2:
Practice Address - City:MILMONT PARK
Practice Address - State:PA
Practice Address - Zip Code:19033-3311
Practice Address - Country:US
Practice Address - Phone:610-619-7300
Practice Address - Fax:610-522-0445
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC7-0003720207Q00000X
PAMD439952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine