1740353598 NPI number — W PENNOCK LAIRD MD PA

Table of content: (NPI 1740353598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740353598 NPI number — W PENNOCK LAIRD MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
W PENNOCK LAIRD MD PA
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:
6
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:
1740353598
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12201 MERIT DR STE 550
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:
75251-3131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-331-9700
Provider Business Mailing Address Fax Number:
972-331-9833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12201 MERIT DR STE 550
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-331-9700
Provider Business Practice Location Address Fax Number:
972-331-9833
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOOSE
Authorized Official First Name:
VICKIE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
972-331-9695

Provider Taxonomy Codes

  • Taxonomy code: 2080P0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1548450216 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 204311909 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 370765501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1306834023 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 194614707 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1575060003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157508601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1790773513 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 370751501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1417110339 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1518955335 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 212234302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1437126364 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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