1194765586 NPI number — LONESTAR PROVIDER NETWORK

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 1194765586 NPI number — LONESTAR PROVIDER NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONESTAR PROVIDER NETWORK
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:
DALLAS MEDICAL SPECIALISTS
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:
1194765586
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 404390
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-4390
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-373-7600
Provider Business Mailing Address Fax Number:
615-373-7651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 FOREST LN
Provider Second Line Business Practice Location Address:
SUITE C-300
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75230-2505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-566-6000
Provider Business Practice Location Address Fax Number:
972-566-6237
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HADDOCK
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
972-566-6000

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0092LT . This is a "BCBS OF TX (AUSTIN)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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