Basic Information
| Provider Information | |||||||||
| NPI: | 1487998696 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ONSITE OCCMED PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CONCENTRA MEDICAL CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5080 SPECTRUM DR | ||||||||
| Address2: | SUITE 1200 WEST | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750014648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723648000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2100 N HWY 360 | ||||||||
| Address2: | SUITE 2201 | ||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750501011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729880441 | ||||||||
| FaxNumber: | 9726410054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | FOGARTY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | TOM | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9723648000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine |
No ID Information.