Provider Demographics
NPI:1508589631
Name:WIDE AWAKE SURGERY PLLC
Entity Type:Organization
Organization Name:WIDE AWAKE SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-979-6222
Mailing Address - Street 1:1202 E ARAPAHO RD STE 122
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-2400
Mailing Address - Country:US
Mailing Address - Phone:469-250-4422
Mailing Address - Fax:
Practice Address - Street 1:1202 E ARAPAHO RD STE 122
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-2400
Practice Address - Country:US
Practice Address - Phone:469-250-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty