Provider Demographics
NPI:1225554173
Name:MESA SPRINGS PHYSICIAN GROUP LLC
Entity Type:Organization
Organization Name:MESA SPRINGS PHYSICIAN GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-371-3338
Mailing Address - Street 1:4801 OLYMPIA PARK PLZ STE 1000
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2090
Mailing Address - Country:US
Mailing Address - Phone:412-588-3546
Mailing Address - Fax:
Practice Address - Street 1:5560 MESA SPRINGS DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-2120
Practice Address - Country:US
Practice Address - Phone:817-406-3423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-22
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty