Provider Demographics
NPI:1275698532
Name:PREMIER DIABETES ENDOCRINOLOGY, PA
Entity Type:Organization
Organization Name:PREMIER DIABETES ENDOCRINOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:OBIALO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-492-9901
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-0378
Mailing Address - Country:US
Mailing Address - Phone:972-492-9901
Mailing Address - Fax:972-492-9902
Practice Address - Street 1:4100 FAIRWAY DR STE 620
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6539
Practice Address - Country:US
Practice Address - Phone:972-492-9901
Practice Address - Fax:972-492-9902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0011LMOtherBCBS
TX167630601Medicaid
TX0011LMOtherBCBS