Basic Information
| Provider Information | |||||||||
| NPI: | 1982074449 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAA SERVICESPLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 41 | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473080041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652840493 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11700 PRESTON RD STE 660-154 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752306112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146999297 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2015 | ||||||||
| LastUpdateDate: | 07/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | VALLOPPILLIL | ||||||||
| AuthorizedOfficialFirstName: | SURESH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2146999297 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.