Basic Information
| Provider Information | |||||||||
| NPI: | 1972118198 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 1551 W CENTRAL ER PHYSICIANS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 910 S KIMBALL AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760929005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175273403 | ||||||||
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| Address1: | 1551 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765044005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542820516 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2020 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | RADLEY | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7135912256 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.