Provider Demographics
NPI:1386746774
Name:LEONARD C BASS MD PA
Entity type:Organization
Organization Name:LEONARD C BASS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:CHANNING
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-873-8545
Mailing Address - Street 1:PO BOX 101330
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33310-1330
Mailing Address - Country:US
Mailing Address - Phone:954-873-8545
Mailing Address - Fax:954-587-7577
Practice Address - Street 1:9750 NW 45TH MNR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-1514
Practice Address - Country:US
Practice Address - Phone:954-873-8545
Practice Address - Fax:954-587-7577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME14256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373957100Medicaid
D51692Medicare UPIN
FL373957100Medicaid