Basic Information
Provider Information | |||||||||
NPI: | 1104490671 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SYNOVATION MEDICAL GROUP TEXAS, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 224 N FAIR OAKS AVE STE 300 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911033618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6266961481 | ||||||||
FaxNumber: | 6266961451 | ||||||||
Practice Location | |||||||||
Address1: | 501 MIDWESTERN PKWY E | ||||||||
Address2: |   | ||||||||
City: | WICHITA FALLS | ||||||||
State: | TX | ||||||||
PostalCode: | 763022302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9402537160 | ||||||||
FaxNumber: | 8334605681 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2021 | ||||||||
LastUpdateDate: | 05/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VARGA | ||||||||
AuthorizedOfficialFirstName: | CLAYTON | ||||||||
AuthorizedOfficialMiddleName: | ALEXANDER | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6266961400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 05/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.