Provider Demographics
NPI:1356484638
Name:TEXAS INSTITUTE OF ORTHOPEDIC SURGERY & SPORTS MEDICINE PLLC
Entity Type:Organization
Organization Name:TEXAS INSTITUTE OF ORTHOPEDIC SURGERY & SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-421-0505
Mailing Address - Street 1:815 IRA E WOODS AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-4012
Mailing Address - Country:US
Mailing Address - Phone:817-421-0505
Mailing Address - Fax:817-421-6060
Practice Address - Street 1:815 IRA E WOODS AVE
Practice Address - Street 2:STE 100
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4012
Practice Address - Country:US
Practice Address - Phone:817-421-0505
Practice Address - Fax:817-421-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6962750001Medicare NSC