1265719140 NPI number — PREMIER GASTROENTEROLOGY OF TEXAS PA

Table of content: (NPI 1265719140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265719140 NPI number — PREMIER GASTROENTEROLOGY OF TEXAS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER GASTROENTEROLOGY OF TEXAS 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:
1265719140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7777 FOREST LANE BLDG. C
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75230-2513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-566-5266
Provider Business Mailing Address Fax Number:
972-566-5245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 FOREST LANE BLDG. C
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75230-2513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-566-5266
Provider Business Practice Location Address Fax Number:
972-566-5245
Provider Enumeration Date:
11/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MALLAT
Authorized Official First Name:
DAMIEN
Authorized Official Middle Name:
BASSAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
972-566-5266

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  L0393 , 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)





Copyright © 2007-2025 www.npivalidator.com