Provider Demographics
NPI:1316946882
Name:BASILICO, FREDERICK CALVIN (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:CALVIN
Last Name:BASILICO
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 1:125 PARKER HILL AVE
Mailing Address - Street 2:STE 450
Mailing Address - City:ROXBURY CROSSING
Mailing Address - State:MA
Mailing Address - Zip Code:02120-2847
Mailing Address - Country:US
Mailing Address - Phone:617-754-5910
Mailing Address - Fax:617-754-5950
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:STE 450
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-754-5910
Practice Address - Fax:617-754-5950
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA41593207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0100153Medicaid
2500051OtherUNITED HEALTH CARE
3039OtherHARVARD PILGRIM HEALTHCAR
C04839Medicare ID - Type Unspecified
3039OtherHARVARD PILGRIM HEALTHCAR