1629034863 NPI number — ORTHOPEDIC SPECIALISTS OF TEXARKANA PLLC

Table of content: (NPI 1629034863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629034863 NPI number — ORTHOPEDIC SPECIALISTS OF TEXARKANA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPEDIC SPECIALISTS OF TEXARKANA 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:
1629034863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7648
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75505-7648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-792-5005
Provider Business Mailing Address Fax Number:
903-791-1569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 TEXAS BLVD.
Provider Second Line Business Practice Location Address:
SUITE 501
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TEXAS
Provider Business Practice Location Address Postal Code:
75501
Provider Business Practice Location Address Country Code:
UM
Provider Business Practice Location Address Telephone Number:
903-792-5005
Provider Business Practice Location Address Fax Number:
903-791-1569
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEHAAN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
903-792-5005

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G2594 , 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: 5G239 . This is a "ARKANSAS MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 109415302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100754980A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 131747002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 94AU . This is a "TEXAS BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: CE7233 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 85756 . This is a "ARKANSAS BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 180802400 . This is a "DEPT OF LABOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com