1972688281 NPI number — BRITT SHORE MCGANNON LPT

Table of content: BRITT SHORE MCGANNON LPT (NPI 1972688281)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972688281 NPI number — BRITT SHORE MCGANNON LPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGANNON
Provider First Name:
BRITT
Provider Middle Name:
SHORE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HASON
Provider Other First Name:
BRITT
Provider Other Middle Name:
SHORE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972688281
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKWALL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75087-9000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-771-0999
Provider Business Mailing Address Fax Number:
972-771-2281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5501 GORDON SMITH ROAD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ROWLETT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75089-3210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-475-5122
Provider Business Practice Location Address Fax Number:
972-475-1299
Provider Enumeration Date:
10/26/2006

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:  1137446 , 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: 165348701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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