Provider Demographics
NPI:1326108200
Name:IMMANUEL BRAIN, SPINE AND NERVE SURGERY, PA
Entity Type:Organization
Organization Name:IMMANUEL BRAIN, SPINE AND NERVE SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:TEAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-795-7337
Mailing Address - Street 1:624 MATLOCK CENTRE CIR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-2536
Mailing Address - Country:US
Mailing Address - Phone:817-795-7337
Mailing Address - Fax:817-795-8393
Practice Address - Street 1:624 MATLOCK CENTRE CIR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2536
Practice Address - Country:US
Practice Address - Phone:817-795-7337
Practice Address - Fax:817-795-8393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2368207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161312701Medicaid
TX00764VMedicare ID - Type Unspecified