1386019784 NPI number — PEBBLE CREEK EMERGENCY PHYSICIANS PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386019784 NPI number — PEBBLE CREEK EMERGENCY PHYSICIANS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEBBLE CREEK EMERGENCY PHYSICIANS 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:
1386019784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13737 NOEL RD
Provider Second Line Business Mailing Address:
SUITE 1600
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75240-1331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-401-2386
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-5175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-401-2386
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GATEWOOD
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
469-401-2386

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)





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