1083658751 NPI number — DR. ADRIANNE DEEM MD

Table of content: DR. ADRIANNE DEEM MD (NPI 1083658751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083658751 NPI number — DR. ADRIANNE DEEM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEEM
Provider First Name:
ADRIANNE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1083658751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6100 HARRIS PKWY
Provider Second Line Business Mailing Address:
#245
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76132-4124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-346-5336
Provider Business Mailing Address Fax Number:
817-346-5366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 W. TERRELL AVE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-250-7035
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2006

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: 207V00000X , with the licence number:  L3838 , 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: 82954X . This is a "BC/BS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 7507354 . This is a "AETNA HMO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 160059984 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 150755001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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