1114073830 NPI number — PENNISSI P. TAYLOR PH.D,PC

Table of content: (NPI 1114073830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114073830 NPI number — PENNISSI P. TAYLOR PH.D,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENNISSI P. TAYLOR PH.D,PC
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:
THE TAYLOR CLINIC
Provider Other Organization Name Type Code:
3
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:
1114073830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1391
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROWNWOOD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76804-1391
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-649-4357
Provider Business Mailing Address Fax Number:
325-646-0919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 CENTER AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNWOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76801-2919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-649-4357
Provider Business Practice Location Address Fax Number:
325-646-0919
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
PENNISSI
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
325-649-4357

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  15762 , 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: 0007QC . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 203875 . This is a "VALUE OPTIONS INSURANCE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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