Basic Information
Provider Information | |||||||||
NPI: | 1821019555 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BASS | ||||||||
FirstName: | NANCY | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9000 W WISCONSIN AVE | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532264874 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4142663464 | ||||||||
FaxNumber: | 4142663466 | ||||||||
Practice Location | |||||||||
Address1: | 9000 W WISCONSIN AVE | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532264874 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4142663464 | ||||||||
FaxNumber: | 4142663466 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2006 | ||||||||
LastUpdateDate: | 09/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | 23087 | WI | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
ID | Type | State | Issuer | Description | P00412275 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000221329 | 01 | OH | UNISON | OTHER | 2098807 | 01 | OH | AETNA | OTHER | 2114518 | 05 | OH |   | MEDICAID | 000000525878 | 01 | OH | ANTHEM | OTHER | 1015724700001 | 01 | PA | PA MEDICAID | OTHER | 2114518 | 01 | OH | BCMH | OTHER | 363346 | 01 | OH | BUCKEYE | OTHER | 000000182734 | 01 | OH | ANTHEM | OTHER | 740064 | 01 | OH | BUCKEYE | OTHER |