Provider Demographics
NPI:1457306656
Name:SDG PHYSICIANS GROUP PA
Entity Type:Organization
Organization Name:SDG PHYSICIANS GROUP PA
Other - Org Name:SDG PHYSICIANS GROUP PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:NEFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-552-6719
Mailing Address - Street 1:620 E SOUTHLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6236
Mailing Address - Country:US
Mailing Address - Phone:817-552-6730
Mailing Address - Fax:817-552-6722
Practice Address - Street 1:620 E SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6236
Practice Address - Country:US
Practice Address - Phone:817-552-6730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
00X497Medicare PIN
00X495Medicare PIN
00X496Medicare PIN
00X493Medicare PIN
00X494Medicare PIN