1093833576 NPI number — MARK EDWARD ATHANS LSA

Table of content: MARK EDWARD ATHANS LSA (NPI 1093833576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093833576 NPI number — MARK EDWARD ATHANS LSA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ATHANS
Provider First Name:
MARK
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSA
Provider Gender Code:
M

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:
1093833576
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3005
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77378-3005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-227-2457
Provider Business Mailing Address Fax Number:
214-764-0880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15103 TX-75
Provider Second Line Business Practice Location Address:
#242
Provider Business Practice Location Address City Name:
WILLIS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-227-2457
Provider Business Practice Location Address Fax Number:
214-764-0880
Provider Enumeration Date:
03/26/2007

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: 246ZC0007X , with the licence number:  SA00029 , 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: 0004JR . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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