Basic Information
| Provider Information | |||||||||
| NPI: | 1760625032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASSEY | ||||||||
| FirstName: | EDEMEKONG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 S YALE AVE STE 1200 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184886687 | ||||||||
| FaxNumber: | 9184886098 | ||||||||
| Practice Location | |||||||||
| Address1: | 6161 S YALE AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185024254 | ||||||||
| FaxNumber: | 9185022265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 33254 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 2013002759 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | P01272014 | 01 | MO | PALMETTO GBA RAILROAD | OTHER |