Basic Information
| Provider Information | |||||||||
| NPI: | 1992198188 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | NI | ||||||||
| FirstName: | JACK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5870 HIATUS RD | ||||||||
| Address2: | PE DEPT - WEST REGION | ||||||||
| City: | TAMARAC | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333216424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884472362 | ||||||||
| FaxNumber: | 8655607110 | ||||||||
| Practice Location | |||||||||
| Address1: | BAYLOR SCOTT & WHITE ALL SAINTS MEDICAL CENTER | ||||||||
| Address2: | 1400 8TH AVE | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179262544 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2015 | ||||||||
| LastUpdateDate: | 11/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R4609 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.