1649403106 NPI number — GREGG T. PODLESKI, D.O. P.A.

Table of content: (NPI 1649403106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649403106 NPI number — GREGG T. PODLESKI, D.O. P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREGG T. PODLESKI, D.O. P.A.
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:
1649403106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 851858
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESQUITE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75185-1858
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-613-7776
Provider Business Mailing Address Fax Number:
972-613-7775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2540 N GALLOWAY AVE
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
MESQUITE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75150-6306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-613-7776
Provider Business Practice Location Address Fax Number:
972-613-7775
Provider Enumeration Date:
09/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PODLESKI
Authorized Official First Name:
GREGG
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
OWNER / CEO
Authorized Official Telephone Number:
972-613-7776

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  J7138 , 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: 3342342 . This is a "BLUE LINK" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: N35U . This is a "BLUE CROSS PROVIDER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 03034994601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4570998 . This is a "AETNA PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 180405500 . This is a "DOL ACS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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