Basic Information
| Provider Information | |||||||||
| NPI: | 1558538520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY PSYCHIATRIC MEDICINE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7808 CLODUS FIELDS DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725667260 | ||||||||
| FaxNumber: | 9725666237 | ||||||||
| Practice Location | |||||||||
| Address1: | 7808 CLODUS FIELDS DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725667260 | ||||||||
| FaxNumber: | 9725666237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2008 | ||||||||
| LastUpdateDate: | 02/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9724018726 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1974578-01 | 05 | TX | MEDICAID |