1376565341 NPI number — MEDISTAT GROUP ASSOCIATES, INC.

Table of content: (NPI 1376565341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376565341 NPI number — MEDISTAT GROUP ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDISTAT GROUP ASSOCIATES, INC.
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:
1376565341
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2617 BOLTON BOONE DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
DESOTO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75115-2074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-709-1781
Provider Business Mailing Address Fax Number:
972-709-1782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2617 BOLTON BOONE DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
DESOTO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75115-2074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-709-1781
Provider Business Practice Location Address Fax Number:
972-709-1782
Provider Enumeration Date:
07/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHIPMAN
Authorized Official First Name:
TERI
Authorized Official Middle Name:
LOUISE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
972-709-1781

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2278P1005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0100X , with the licence number: G6955 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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