Basic Information
| Provider Information | |||||||||
| NPI: | 1477741486 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS EM-1 MEDICAL SERVICES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 MAIN ST | ||||||||
| Address2: | SUITE 5200 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2147122000 | ||||||||
| FaxNumber: | 2147122444 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | SULPHUR SPRINGS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754822105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038857671 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2007 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | JERNBERG | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2147122000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 152242709 | 05 | TX | MEDICAID | 0055QQ | 01 | TX | BCBS | OTHER |