1891770731 NPI number — DENTON PHYSICAL MEDICINE PAIN

Table of content: (NPI 1891770731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891770731 NPI number — DENTON PHYSICAL MEDICINE PAIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTON PHYSICAL MEDICINE PAIN
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:
PARCHELLE D CONNALLY MD
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:
1891770731
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5801 SHOREFRONT LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWER MOUND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75022-5698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-539-1200
Provider Business Mailing Address Fax Number:
972-539-1221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4320 WINDSOR CENTRE TRL
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
FLOWER MOUND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75028-1858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-539-1200
Provider Business Practice Location Address Fax Number:
972-539-1221
Provider Enumeration Date:
12/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CONNALLY
Authorized Official First Name:
PARCHELLE
Authorized Official Middle Name:
DENIESE
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
972-539-1200

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  J8969 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0000X , with the licence number: J8969 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 036324401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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