Basic Information
Provider Information | |||||||||
NPI: | 1184057309 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STAR MEDICAL CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STAR MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1707 MARKET PL STE 300 | ||||||||
Address2: |   | ||||||||
City: | IRVING | ||||||||
State: | TX | ||||||||
PostalCode: | 750638046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8174211066 | ||||||||
FaxNumber: | 8175071800 | ||||||||
Practice Location | |||||||||
Address1: | 4100 MAPLESHADE LANE | ||||||||
Address2: |   | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 75093 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9722651050 | ||||||||
FaxNumber: | 9722651252 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2013 | ||||||||
LastUpdateDate: | 03/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOWLER | ||||||||
AuthorizedOfficialFirstName: | JORDAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 8174211066 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X |   | TX | Y |   | Hospitals | Special Hospital |   |
No ID Information.