Keith Samuel Bass, NP-C
Individual provider Active NPI Family Nurse Practitioner · Anna, IL
NPI 1114440179 · NPPES record last updated Jan 5, 2024
Key facts
- NPI
- 1114440179
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Nurse Practitioner 363LF0000X
- License
- 277002840 (IL)
- Practice address
- 513 N Main St
Anna, IL 62906-1668 - Phone
- (618) 833-4471
- NPI assigned
- Jul 21, 2017
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 4
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20170905002980 | IL | Practitioner - Nurse Practitioner | 7517230014 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Master of Arts, Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 277002840 | IL | MD | Family Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Claripath Psychiatry PLLC | Current |
Accepting new patients | |
| Rural Health, Inc. | Current |
Accepting new patients | |
| Rural Health, Inc. | Current |
Accepting new patients | |
| Rural Health, Inc. | Past | Accepting new patients |
Locations
330 S Main St
Anna, IL 62906
Phone (618) 270-7879
513 N Main St
Anna, IL 62906
Phone (618) 833-4471
400 S Broadway
Goreville, IL 62939
Phone (618) 995-1002
803 N 1st St
Vienna, IL 62995
Phone (618) 658-2811
Interoperability endpoints
- keith.bass.1@7601.direct.athenahealth.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner | 363LF0000X | 209015848 | IL | |
| Family Nurse Practitioner | 363LF0000X | 277002840 | IL | Yes |
Addresses
Primary practice location
513 N Main St
Anna, IL 62906-1668
Mailing address
20 Lynwood LN
Anna, IL 62906-3265
Phone (217) 898-3462
Other providers in Anna, IL
- Arrowleaf
- Morgan Atherton
- Halley M Barke
- Anthony Shane Barker
- Olivia Leann Barker
- Nancy L Bass
- Steven M Beatty
- Danece Lynn Bennett
- Tessa Lea Binversie
- Randall D Boen
All providers in Anna, IL · Family Nurse Practitioner in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 5, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.