1063443703 NPI number — RANDALL W CRIM MD

Table of content: RANDALL W CRIM MD (NPI 1063443703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063443703 NPI number — RANDALL W CRIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRIM
Provider First Name:
RANDALL
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1063443703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11551 FOREST CENTRAL DR
Provider Second Line Business Mailing Address:
SUITE 133
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75243-3920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-343-8565
Provider Business Mailing Address Fax Number:
214-343-3689

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 N MACARTHUR BLVD
Provider Second Line Business Practice Location Address:
SUITE 750
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75061-2256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-759-2040
Provider Business Practice Location Address Fax Number:
972-759-2045
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208C00000X , with the licence number:  H1941 , 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)

  • Identifier: 103840801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103840803 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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