Basic Information
| Provider Information | |||||||||
| NPI: | 1629367578 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST EMERGENCY GOOD SAMARITAN, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6451 BRENTWOOD STAIR ROAD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761123200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174514208 | ||||||||
| FaxNumber: | 8175633699 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628642857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174514208 | ||||||||
| FaxNumber: | 8175633699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2011 | ||||||||
| LastUpdateDate: | 03/31/2011 | ||||||||
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| AuthorizedOfficialLastName: | CRUZEN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8174514208 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.