Basic Information
Provider Information | |||||||||
NPI: | 1982809257 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICIANS MEDICAL CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TEXAS HEALTH CENTER FOR DIAGNOSTICS AND SURGERY PLANO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 676266 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752676266 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9724196704 | ||||||||
FaxNumber: | 9724198188 | ||||||||
Practice Location | |||||||||
Address1: | 6020 W PARKER RD | ||||||||
Address2: |   | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 750938171 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9724032791 | ||||||||
FaxNumber: | 9724198188 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2007 | ||||||||
LastUpdateDate: | 02/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROBERTSON | ||||||||
AuthorizedOfficialFirstName: | LARRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9724032791 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   | TX | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 174662002 | 05 | TX |   | MEDICAID | HH1070 | 01 | TX | BCBS PROVIDER NUMBER | OTHER |