1649788373 NPI number — PBH MEDICAL, LLC

Table of content: (NPI 1649788373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649788373 NPI number — PBH MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PBH MEDICAL, LLC
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:
PRIME BEHAVIORAL HEALTH
Provider Other Organization Name Type Code:
3
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:
1649788373
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 RIVER OAKS DR STE 140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-6882
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-778-8884
Provider Business Mailing Address Fax Number:
817-385-6540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 RIVER OAKS DR STE 140
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHLAKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76092-6882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-778-8884
Provider Business Practice Location Address Fax Number:
817-385-6540
Provider Enumeration Date:
01/16/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
VISHAL
Authorized Official Middle Name:
PANKAJKUMAR
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
817-778-8884

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  Q5097 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: Q5097 , 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)