Basic Information
| Provider Information | |||||||||
| NPI: | 1134590151 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTRY ROAD EMERGENCY PHYSICIANS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98953 | ||||||||
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| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891938684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4694012386 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2830 CALDER ST | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4694012386 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2015 | ||||||||
| LastUpdateDate: | 11/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | GATEWOOD | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4694012386 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.