1043702111 NPI number — GREATER DALLAS PAIN INSTITUTE PLLC

Table of content: (NPI 1043702111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043702111 NPI number — GREATER DALLAS PAIN INSTITUTE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATER DALLAS PAIN INSTITUTE PLLC
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:
DFW INTERVENTIONAL PAIN INSTITUTE
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:
1043702111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5544 BIG RIVER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THE COLONY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75056-3778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-816-0421
Provider Business Mailing Address Fax Number:
972-370-2609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7300 ELDORADO PKWY STE 255
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCKINNEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-816-0421
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HILL
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
972-816-0421

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  P9087 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X , with the licence number: P9087 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0014X , with the licence number: P9087 , 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)