1124085956 NPI number — SURGICAL GROUP OF NORTH TEXAS, PLLC

Table of content: (NPI 1124085956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124085956 NPI number — SURGICAL GROUP OF NORTH TEXAS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURGICAL GROUP OF NORTH TEXAS, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124085956
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 204803
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75320-4803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-251-0070
Provider Business Mailing Address Fax Number:
817-527-6610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1056 TEXAN TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAPEVINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76051-3703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-251-0070
Provider Business Practice Location Address Fax Number:
817-527-6610
Provider Enumeration Date:
04/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MATIN
Authorized Official First Name:
SINA
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
817-251-0070

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LA2100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)