Provider Demographics
NPI:1164419727
Name:TYLER NEUROSURGICAL ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:TYLER NEUROSURGICAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GIDEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-590-8012
Mailing Address - Street 1:700 OLYMPIC PLAZA CIR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1955
Mailing Address - Country:US
Mailing Address - Phone:903-595-2441
Mailing Address - Fax:903-595-0743
Practice Address - Street 1:700 OLYMPIC PLAZA CIR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1955
Practice Address - Country:US
Practice Address - Phone:903-595-2441
Practice Address - Fax:903-595-0743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX094747501Medicaid
TX00GT71Medicare ID - Type Unspecified