1770711392 NPI number — OMS PHYSICIANS GROUP PLLC

Table of content: (NPI 1770711392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770711392 NPI number — OMS PHYSICIANS GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMS PHYSICIANS 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:
1770711392
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1422 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-7625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-424-1166
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1422 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
SOUTHLAKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76092-7625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-424-1166
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-424-1166

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: H87528 . This is a "UPIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".