Provider Demographics
NPI:1083963201
Name:GRAPEVINE RHEUMATOLOGY CLINIC,LLC
Entity Type:Organization
Organization Name:GRAPEVINE RHEUMATOLOGY CLINIC,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:UZMA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SYEDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-451-3452
Mailing Address - Street 1:PO BOX 3767
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76099-3767
Mailing Address - Country:US
Mailing Address - Phone:312-451-3452
Mailing Address - Fax:
Practice Address - Street 1:210 N PARK BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-6985
Practice Address - Country:US
Practice Address - Phone:817-224-2215
Practice Address - Fax:817-796-1500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2540261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ132349Medicare UPIN