1568404622 NPI number — BRENT WILLIAM ROBINSON M.D.

Table of content: ALYSSA ANN ROTZENBERG (NPI 1073278784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568404622 NPI number — BRENT WILLIAM ROBINSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBINSON
Provider First Name:
BRENT
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1568404622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 846098
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:
75284-6098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-606-6400
Provider Business Mailing Address Fax Number:
903-606-1522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2604 SAINT MICHAEL DR STE 345
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-2378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-838-5500
Provider Business Practice Location Address Fax Number:
903-838-7402
Provider Enumeration Date:
06/12/2006

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: 207R00000X , with the licence number:  K0175 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: K0175 , 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: 100147780A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 97560 . This is a "BCBS OF ARKANSAS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 0005940447 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 131289001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 173320000 . This is a "QUAL CHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 3390657 . This is a "BLUE LINK" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 045226001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 86V156 . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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