Basic Information
| Provider Information | |||||||||
| NPI: | 1114925229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MISENHIMER | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 MURCHISON DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799022921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155951099 | ||||||||
| FaxNumber: | 9155952933 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 MURCHISON | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799022921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155347465 | ||||||||
| FaxNumber: | 9155341289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | G3614 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0117X | G3614 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 120130301 | 05 | TX | MEDICAID |