1629034863 NPI number — ORTHOPEDIC SPECIALISTS OF TEXARKANA 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 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".




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