1811131758 NPI number — HAROLD B.EUDALY JR., M.D.PA

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 1811131758 NPI number — HAROLD B.EUDALY JR., M.D.PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAROLD B.EUDALY JR., M.D.PA
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:
1811131758
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6300 RIDGLEA PLACE
Provider Second Line Business Mailing Address:
SUITE 814
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76116-5704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-763-0022
Provider Business Mailing Address Fax Number:
817-763-0027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6300 RIDGLEA PL
Provider Second Line Business Practice Location Address:
SUITE 814
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76116-5704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-763-0022
Provider Business Practice Location Address Fax Number:
817-763-0027
Provider Enumeration Date:
04/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EUDALY
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-763-0022

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  C6930 , 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: 1881792026 . This is a "OLD NPI" identifier . This identifiers is of the category "OTHER".




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