Provider Demographics
NPI:1376698944
Name:PHYSIATRY SERVICE ORGANIZATION, INC.
Entity Type:Organization
Organization Name:PHYSIATRY SERVICE ORGANIZATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-403-3959
Mailing Address - Street 1:PO BOX 678413
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8413
Mailing Address - Country:US
Mailing Address - Phone:214-403-3959
Mailing Address - Fax:817-284-3505
Practice Address - Street 1:103 N 1ST ST
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-3033
Practice Address - Country:US
Practice Address - Phone:214-403-3959
Practice Address - Fax:817-284-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty