Provider Demographics
NPI:1134686926
Name:GRAND PRAIRIE PHYSICIAN GROUP LLC
Entity Type:Organization
Organization Name:GRAND PRAIRIE PHYSICIAN GROUP LLC
Other - Org Name:GRAND PRAIRIE PHYSICIANS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEL BOSQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-826-4294
Mailing Address - Street 1:517 N CARRIER PKWY STE J
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-5484
Mailing Address - Country:US
Mailing Address - Phone:214-677-0639
Mailing Address - Fax:214-677-0539
Practice Address - Street 1:517 N CARRIER PKWY STE J
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-5484
Practice Address - Country:US
Practice Address - Phone:214-677-0639
Practice Address - Fax:214-677-0539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-27
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty