Basic Information
Provider Information | |||||||||
NPI: | 1639308539 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INNOVATIVE EMERGENCY PHYSICIANS OF SUNNYVALE PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9 HARBOUR TOWN CT | ||||||||
Address2: |   | ||||||||
City: | FRISCO | ||||||||
State: | TX | ||||||||
PostalCode: | 750346819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8774854474 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 231 S COLLINS RD | ||||||||
Address2: |   | ||||||||
City: | SUNNYVALE | ||||||||
State: | TX | ||||||||
PostalCode: | 751824624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2149069398 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2009 | ||||||||
LastUpdateDate: | 02/23/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ARAI | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2149069398 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 208113501 | 05 | TX |   | MEDICAID | 616483 | 01 |   | DEPT OF LABOR FECA OWCP | OTHER | DQ5606 | 01 | TX | RRMCARE | OTHER |