Basic Information
Provider Information | |||||||||
NPI: | 1093062168 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONCENTRA PRIMARY CARE PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CONCENTRA PRIMARY CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5080 SPECTRUM DRIVE | ||||||||
Address2: | SUITE 1200 WEST | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750014648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9727207772 | ||||||||
FaxNumber: | 2147754502 | ||||||||
Practice Location | |||||||||
Address1: | 2424 SIR BARTON WAY | ||||||||
Address2: | SUITE 175 | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405092531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592334882 | ||||||||
FaxNumber: | 8592334886 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2012 | ||||||||
LastUpdateDate: | 02/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HASSETT | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT / TREASURER | ||||||||
AuthorizedOfficialTelephone: | 9723648000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 363LF0000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363AM0700X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.