Basic Information
| Provider Information | |||||||||
| NPI: | 1265408561 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALM VALLEY EMERGENCY PHYSICIANS SPECIALISTS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2686 W ALTON GLOOR BLVD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785204054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565479561 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1040 W JEFFERSON ST | ||||||||
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| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785206338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566985400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 07/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | HUSSAIN | ||||||||
| AuthorizedOfficialFirstName: | KHADIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9565479552 | ||||||||
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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 | 207PE0004X | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 151894601 | 05 | TX | MEDICAID |