1205465200 NPI number — ADRIENNE L. PRENTISS, MD PA

Table of content: (NPI 1205465200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205465200 NPI number — ADRIENNE L. PRENTISS, MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADRIENNE L. PRENTISS, MD PA
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:
1205465200
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
807 CROWN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KELLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76248-5464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-939-8089
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1704 TENNISON PKWY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEYVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76034-6297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-251-1225
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
PRENTISS
Authorized Official First Name:
ADRIENNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
817-939-8089

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: H03548 . This is a "UPIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0060HP . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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