Provider Demographics
NPI:1861532103
Name:BASS, REBECCA LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:LYNN
Last Name:BASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 CHARTER BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4854
Mailing Address - Country:US
Mailing Address - Phone:478-757-1411
Mailing Address - Fax:478-757-1288
Practice Address - Street 1:350 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3838
Practice Address - Country:US
Practice Address - Phone:478-464-1442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA041074174400000X
GA41074207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000686518AMedicaid
GA29BDBTSMedicare ID - Type Unspecified