Basic Information
| Provider Information | |||||||||
| NPI: | 1679135420 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAI PARTICIPANT 9 PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 639676 | ||||||||
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| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452639676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592914800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1550 WATERS RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750576011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728994401 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2019 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR MNGR IN CRED/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4846432639 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.