Provider Demographics
NPI:1548257876
Name:BASISTA, MICHAEL H (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:BASISTA
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:ONE SEAGATE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604
Mailing Address - Country:US
Mailing Address - Phone:419-824-7250
Mailing Address - Fax:419-885-3921
Practice Address - Street 1:5700 MONROE ST UNIT 103
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2771
Practice Address - Country:US
Practice Address - Phone:419-843-7996
Practice Address - Fax:419-841-7725
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052150B207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0816040Medicaid
MI4796124Medicaid
4290317OtherAETNA
000000581398OtherANTHEM
MI4632355Medicaid
01309OtherPARAMOUNT
MI4796142Medicaid
P00659818OtherRAILROAD MEDICARE
P00659818OtherRAILROAD MEDICARE
$$$$$$$$$-001OtherMMO
MI4632355Medicaid
OHBA7336901Medicare PIN
4290317OtherAETNA