1013248566 NPI number — HAZEL SPORTS MEDICINE AND ORTHOPAEDICS PA

Table of content: (NPI 1013248566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013248566 NPI number — HAZEL SPORTS MEDICINE AND ORTHOPAEDICS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAZEL SPORTS MEDICINE AND ORTHOPAEDICS PA
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:
1013248566
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1766
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKWALL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75087-1766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-463-4313
Provider Business Mailing Address Fax Number:
972-463-4245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7501 LAKEVIEW PKWY
Provider Second Line Business Practice Location Address:
SUITE 245
Provider Business Practice Location Address City Name:
ROWLETT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75088-9322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-463-4313
Provider Business Practice Location Address Fax Number:
972-463-4245
Provider Enumeration Date:
01/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HAZEL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
PHYSICIAN/ OWNER
Authorized Official Telephone Number:
972-463-4313

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  J2448 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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