Provider Demographics
NPI:1316940547
Name:BASHUK, ROBERT GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GLEN
Last Name:BASHUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3875 AUSTELL RD
Mailing Address - Street 2:STE 204
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1153
Mailing Address - Country:US
Mailing Address - Phone:770-819-1717
Mailing Address - Fax:770-819-1140
Practice Address - Street 1:4460 AUSTELL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1844
Practice Address - Country:US
Practice Address - Phone:770-941-4716
Practice Address - Fax:770-941-3047
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0264512084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000345639SMedicaid
GA130014132OtherRAILROAD MEDICARE
GA13BDCQBMedicare ID - Type Unspecified
GAD39360Medicare UPIN
GA130014132Medicare PIN