1144511353 NPI number — MASS EFFECT MEDICAL GROUP PLLC

Table of content: (NPI 1144511353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144511353 NPI number — MASS EFFECT MEDICAL GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASS EFFECT MEDICAL GROUP 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:
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:
1144511353
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12015 QUINCY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75230-2121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-202-0789
Provider Business Mailing Address Fax Number:
940-241-4022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 AME DR
Provider Second Line Business Practice Location Address:
APT 1103
Provider Business Practice Location Address City Name:
DENTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-260-7745
Provider Business Practice Location Address Fax Number:
877-442-9313
Provider Enumeration Date:
04/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LATIF
Authorized Official First Name:
SHERIF
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
520-250-7440

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  N2620 , 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: 1144511353 . This is a "GRP NPI" identifier . This identifiers is of the category "OTHER".




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