1477884740 NPI number — STAR STATE HEART PLLC

Table of content: (NPI 1477884740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477884740 NPI number — STAR STATE HEART PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAR STATE HEART 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:
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:
1477884740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX POX # 731393
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:
75373-1393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-263-0123
Provider Business Mailing Address Fax Number:
512-367-5841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 270
Provider Business Practice Location Address City Name:
LAKEWAY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78738-1782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-263-0123
Provider Business Practice Location Address Fax Number:
512-367-5841
Provider Enumeration Date:
01/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DEMAIO
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
512-263-0123

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  G6655 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: G6655 , 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: 134703111 . This is a "MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 211911702 . This is a "MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TXB144746 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TXB144747 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8F24108 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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