1487057337 NPI number — ORACLE ELECTRODIAGNOSTICS, LLC

Table of content: JOHN ELLIOTT FANNING MD (NPI 1417938762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487057337 NPI number — ORACLE ELECTRODIAGNOSTICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORACLE ELECTRODIAGNOSTICS, LLC
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:
1487057337
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6125 LUTHER LN
Provider Second Line Business Mailing Address:
#175
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75225-6202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-315-6432
Provider Business Mailing Address Fax Number:
214-317-4667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 MONTICELLO AVE
Provider Second Line Business Practice Location Address:
#210
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75205-3442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-315-6432
Provider Business Practice Location Address Fax Number:
214-317-4667
Provider Enumeration Date:
10/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CYR
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
214-315-6432

Provider Taxonomy Codes

  • Taxonomy code: 246ZS0410X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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