Basic Information
| Provider Information | |||||||||
| NPI: | 1457328726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | UFJP PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 570 JACKSONVILLE DR | ||||||||
| Address2: | UFJP BEACHES LIVER AND DIGESTIVE | ||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322503813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042418448 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2006 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME63940 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | ME63940 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 3730948-00 | 05 | FL | MEDICAID | 000553957B | 05 | GA | MEDICAID |