Basic Information
| Provider Information | |||||||||
| NPI: | 1255883625 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOMENTUM ER PHYSICIANS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 93714 | ||||||||
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| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760920116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174210034 | ||||||||
| FaxNumber: | 8174210036 | ||||||||
| Practice Location | |||||||||
| Address1: | 5011 TROUP HWY | ||||||||
| Address2: | 100 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757072562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174210034 | ||||||||
| FaxNumber: | 8174210036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2016 | ||||||||
| LastUpdateDate: | 11/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | NEIMAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | BRAXTON | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 8174210034 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ESQ. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No ID Information.