SOURCE 1 MEDICAL INC

Provider Demographics

• NPI: 1457016966
• Name: SOURCE 1 MEDICAL INC
• Entity Type: Organization
• Organization Name: SOURCE 1 MEDICAL INC
• Authorized Official - Title/Position: CHIEF OPERATIONS OFFICER
• Authorized Official - Prefix: MR
• Authorized Official - First Name: WILLIAM
• Authorized Official - Middle Name: GARRET
• Authorized Official - Last Name: HARRELL
• Authorized Official - Phone: 214-808-2724
• Mailing Address - Street 1: PO BOX 251728
• Mailing Address - City: PLANO
• Mailing Address - State: TX
• Mailing Address - Zip Code: 75025-1517
• Mailing Address - Country: US
• Mailing Address - Phone: 972-801-2190
• Mailing Address - Fax: 972-801-2191
• Practice Address - Street 1: 5425 W SPRING CREEK PKWY STE 270
• Practice Address - City: PLANO
• Practice Address - State: TX
• Practice Address - Zip Code: 75024-4317
• Practice Address - Country: US
• Practice Address - Phone: 972-801-2190
• Practice Address - Fax: 972-801-2191
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2021-11-01
• Last Update Date: 2022-03-24

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	2084N0600X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Clinical Neurophysiology	Group - Multi-Specialty
No	204R00000X	Allopathic & Osteopathic Physicians	Electrodiagnostic Medicine		Group - Multi-Specialty
No	2084N0400X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Neurology	Group - Multi-Specialty
No	225100000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist		Group - Multi-Specialty
No	2251E1300X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist	Electrophysiology, Clinical	Group - Multi-Specialty
No	2251S0007X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist	Sports	Group - Multi-Specialty
No	2251X0800X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist	Orthopedic	Group - Multi-Specialty
No	225X00000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapist		Group - Multi-Specialty
No	225XN1300X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapist	Neurorehabilitation	Group - Multi-Specialty
No	225XP0019X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapist	Physical Rehabilitation	Group - Multi-Specialty
No	246ZE0600X	Technologists, Technicians & Other Technical Service Providers	Specialist/Technologist, Other	Electroneurodiagnostic	Group - Multi-Specialty