1265613889 NPI number — APPLETREE PEDIATRICS, P.A.

Table of content: (NPI 1265613889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265613889 NPI number — APPLETREE PEDIATRICS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
APPLETREE PEDIATRICS, P.A.
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:
1265613889
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1306 DOCTORS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75701-2262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-592-1890
Provider Business Mailing Address Fax Number:
903-592-3222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1306 DOCTORS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75701-2262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-592-1890
Provider Business Practice Location Address Fax Number:
903-592-3222
Provider Enumeration Date:
11/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
J
Authorized Official Middle Name:
KATHLEEN
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
903-592-1890

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  J0605 , 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: 1407940547 . This is a "IDIVIDUAL NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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