Basic Information
Provider Information | |||||||||
NPI: | 1104395359 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMCC CHISHOLM TRAIL PHYSICIANS PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 960 RIDGEVIEW DR STE 140-123 | ||||||||
Address2: |   | ||||||||
City: | ALLEN | ||||||||
State: | TX | ||||||||
PostalCode: | 750135543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143907697 | ||||||||
FaxNumber: | 9724326692 | ||||||||
Practice Location | |||||||||
Address1: | 7445 OAKMONT BLVD | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761323905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8174238444 | ||||||||
FaxNumber: | 8174238446 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2018 | ||||||||
LastUpdateDate: | 07/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEWSOM | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4698308200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.