1417996315 NPI number — GERALD F BULLOCH, MD, PA

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 1417996315 NPI number — GERALD F BULLOCH, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERALD F BULLOCH, 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:
6
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:
1417996315
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 W COLORADO BLVD
Provider Second Line Business Mailing Address:
PAVILION 1 - SUITE 545
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75208-2363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-941-9100
Provider Business Mailing Address Fax Number:
214-941-1949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 W COLORADO BLVD
Provider Second Line Business Practice Location Address:
PAVILION 1 - SUITE 545
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75208-2363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-941-9100
Provider Business Practice Location Address Fax Number:
214-941-1949
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BULLOCH
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MANAGING PARTNER / OWNER
Authorized Official Telephone Number:
214-941-9100

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00TT84 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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