1063786523 NPI number — EA HEALTH PHYSICIANS MEDICAL GROUP TEXAS PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063786523 NPI number — EA HEALTH PHYSICIANS MEDICAL GROUP TEXAS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EA HEALTH PHYSICIANS MEDICAL GROUP TEXAS 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:
1063786523
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 227257
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75222-7257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-759-4765
Provider Business Mailing Address Fax Number:
858-201-4987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12396 WORLD TRADE DR STE 303
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92128-3792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-759-4765
Provider Business Practice Location Address Fax Number:
858-201-4987
Provider Enumeration Date:
03/01/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GRUEN
Authorized Official First Name:
ARTHUR
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
858-759-4765

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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