Basic Information
| Provider Information | |||||||||
| NPI: | 1740537802 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONCENTRA PRIMARY CARE PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CONCENTRA PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5080 SPECTRUM DRIVE | ||||||||
| Address2: | SUITE 1200 WEST | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750014648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727207772 | ||||||||
| FaxNumber: | 2147754502 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 DOVE RUN ROAD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405023536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592694668 | ||||||||
| FaxNumber: | 8592665577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2012 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | HASSETT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 9723648000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363AM0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.