Provider Demographics
NPI:1992710420
Name:BASILIOS, FATHY Z (MD)
Entity type:Individual
Prefix:DR
First Name:FATHY
Middle Name:Z
Last Name:BASILIOS
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 1:1801 WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-6217
Mailing Address - Country:US
Mailing Address - Phone:217-366-1257
Mailing Address - Fax:
Practice Address - Street 1:1801 WINDSOR RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6217
Practice Address - Country:US
Practice Address - Phone:217-366-1257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-073898208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073898 3Medicaid
IL279500OtherMEDICARE GROUP
ILC51248Medicare UPIN
IL036073898 3Medicaid
ILL74331Medicare PIN