Provider Demographics
NPI:1376565341
Name:MEDISTAT GROUP ASSOCIATES, INC.
Entity Type:Organization
Organization Name:MEDISTAT GROUP ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:SHIPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-709-1781
Mailing Address - Street 1:2617 BOLTON BOONE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2074
Mailing Address - Country:US
Mailing Address - Phone:972-709-1781
Mailing Address - Fax:972-709-1782
Practice Address - Street 1:2617 BOLTON BOONE DR
Practice Address - Street 2:SUITE B
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2074
Practice Address - Country:US
Practice Address - Phone:972-709-1781
Practice Address - Fax:972-709-1782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QA0505X, 2081P2900X, 225B00000X, 2278P1005X, 363LA2200X, 363LP2300X
TXG6955261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No225B00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPulmonary Function TechnologistGroup - Multi-Specialty
No2278P1005XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedPulmonary RehabilitationGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00728TMedicare ID - Type UnspecifiedGROUP NUMBER
TXC21376Medicare UPIN
TX8943B6Medicare ID - Type UnspecifiedLOUISE LAMARRE, M.D.
TXC18105Medicare UPIN
TX8684B9Medicare ID - Type UnspecifiedJACQUES ROY, M.D