Basic Information
Provider Information | |||||||||
NPI: | 1649393877 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | 24 ON PHYSICIANS PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 403631 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303843631 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7707400895 | ||||||||
FaxNumber: | 7707400896 | ||||||||
Practice Location | |||||||||
Address1: | 1600 11TH ST | ||||||||
Address2: |   | ||||||||
City: | WICHITA FALLS | ||||||||
State: | TX | ||||||||
PostalCode: | 763014300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9407643983 | ||||||||
FaxNumber: | 9407643978 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2007 | ||||||||
LastUpdateDate: | 06/04/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FULLER | ||||||||
AuthorizedOfficialFirstName: | DAN | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 7707400895 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   |
No ID Information.