Basic Information
| Provider Information | |||||||||
| NPI: | 1124639638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITEHEAD | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | CNIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1819 JAY ELL DR | ||||||||
| Address2: | |||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750812063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883442947 | ||||||||
| FaxNumber: | 8886942947 | ||||||||
| Practice Location | |||||||||
| Address1: | 1819 JAY ELL DR | ||||||||
| Address2: | |||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750812063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883442947 | ||||||||
| FaxNumber: | 8886942947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2020 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | 1104 | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
ID Information
| ID | Type | State | Issuer | Description | 1104 | 01 | CNIM | OTHER |