Provider Demographics
NPI:1851382568
Name:BASTIAN, SAMUEL R (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:BASTIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:222 22ND AVE N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1852
Mailing Address - Country:US
Mailing Address - Phone:615-284-2222
Mailing Address - Fax:
Practice Address - Street 1:2339 HILLSBORO RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37069-6225
Practice Address - Country:US
Practice Address - Phone:615-224-1970
Practice Address - Fax:615-916-3946
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD21179207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1504970Medicaid
TNF67996Medicare UPIN
30781301Medicare PIN