Provider Demographics
NPI:1144282757
Name:BASELLO, GINA M (DO)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:BASELLO
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:80 MARCUS DR
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4230
Mailing Address - Country:US
Mailing Address - Phone:631-391-7887
Mailing Address - Fax:631-454-4163
Practice Address - Street 1:133-03 JAMAICA AVENUE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418
Practice Address - Country:US
Practice Address - Phone:718-657-7093
Practice Address - Fax:718-558-5314
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2013-01-17
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Provider Licenses
StateLicense IDTaxonomies
NY222962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02312554Medicaid
H68153Medicare UPIN
NY0105PSMedicare PIN