1356323034 NPI number — SCOTT STEGALL PA-C

Table of content: SCOTT STEGALL PA-C (NPI 1356323034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356323034 NPI number — SCOTT STEGALL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEGALL
Provider First Name:
SCOTT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1356323034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 841656
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:
75284-1656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-531-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5414 S BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-1335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-581-1601
Provider Business Practice Location Address Fax Number:
903-581-1638
Provider Enumeration Date:
11/17/2005

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: 363AM0700X , with the licence number:  PA01268 , 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: 8854MB . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8780MD . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 337197303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01811994 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01811499 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 337197302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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