Provider Demographics
NPI:1497941710
Name:EXTRACARE PALLIATIVE CONSULTANTS, PA
Entity Type:Organization
Organization Name:EXTRACARE PALLIATIVE CONSULTANTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:PACL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-366-4882
Mailing Address - Street 1:16721 DECKER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MANOR
Mailing Address - State:TX
Mailing Address - Zip Code:78653-5012
Mailing Address - Country:US
Mailing Address - Phone:479-366-4882
Mailing Address - Fax:866-838-7772
Practice Address - Street 1:16721 DECKER CREEK DR
Practice Address - Street 2:
Practice Address - City:MANOR
Practice Address - State:TX
Practice Address - Zip Code:78653-5012
Practice Address - Country:US
Practice Address - Phone:479-366-4882
Practice Address - Fax:866-838-7772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6493207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE29321Medicare UPIN
TX00771KMedicare PIN
TX1458176-01Medicaid