1821122078 NPI number — GREYDON BLAIR CALLAWAY PT, OCS

Table of content: GREYDON BLAIR CALLAWAY PT, OCS (NPI 1821122078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821122078 NPI number — GREYDON BLAIR CALLAWAY PT, OCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALLAWAY
Provider First Name:
GREYDON
Provider Middle Name:
BLAIR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, OCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CALLAWAY
Provider Other First Name:
GRADY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, OCS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1821122078
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 OAK LAWN AVE
Provider Second Line Business Mailing Address:
STE 670
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75219-4399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-528-3378
Provider Business Mailing Address Fax Number:
214-528-3379

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3131 TURTLE CREEK BLVD
Provider Second Line Business Practice Location Address:
SUITE 615
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75219-5405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-528-3378
Provider Business Practice Location Address Fax Number:
214-528-3379
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1148889 , 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)





Copyright © 2007-2024 www.npivalidator.com