1134774722 NPI number — TEXAS EMERGENCY MEDICINE GROUP, LLP

Table of content: (NPI 1134774722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134774722 NPI number — TEXAS EMERGENCY MEDICINE GROUP, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS EMERGENCY MEDICINE GROUP, LLP
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:
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:
1134774722
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8292
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76124-0292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-451-4208
Provider Business Mailing Address Fax Number:
817-563-3699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 MONTGOMERY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAHAM
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76450-4240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-451-4208
Provider Business Practice Location Address Fax Number:
817-563-3699
Provider Enumeration Date:
08/09/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GUNDERSEN
Authorized Official First Name:
JASEN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
817-451-4208

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com