1497102990 NPI number — HEALTHWORKS MED GROUP OF TEXAS DARLINGTON P A

Table of content: (NPI 1497102990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497102990 NPI number — HEALTHWORKS MED GROUP OF TEXAS DARLINGTON P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHWORKS MED GROUP OF TEXAS DARLINGTON 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:
PREMISE HEALTH 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:
1497102990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5500 MARYLAND WAY STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-4993
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
TERMINAL A39, RAMP LEVEL
Provider Second Line Business Practice Location Address:
DALLAS FORT WORTH INTERNATIONAL AIRPORT
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-425-7295
Provider Business Practice Location Address Fax Number:
972-425-2495
Provider Enumeration Date:
05/16/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HINITT
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
844-407-7557

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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