1306022520 NPI number — MAINLAND MULTI SPECIALTY GROUP PLLC

Table of content: (NPI 1306022520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306022520 NPI number — MAINLAND MULTI SPECIALTY GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINLAND MULTI SPECIALTY GROUP 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:
1306022520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 HEALTH PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-4525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-373-7600
Provider Business Mailing Address Fax Number:
866-346-1426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6807 EMMETT F. LOWRY EXPRESSWAY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
TEXAS CITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-935-2930
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
REBOK
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
GROUP VP/AO
Authorized Official Telephone Number:
615-372-5004

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 194700401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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