Provider Demographics
NPI:1598172033
Name:SOUTHLAKE EMERGICARE PLLC
Entity Type:Organization
Organization Name:SOUTHLAKE EMERGICARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:PECKENPAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-485-4474
Mailing Address - Street 1:PO BOX 720508
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-4373
Mailing Address - Country:US
Mailing Address - Phone:877-485-4474
Mailing Address - Fax:405-341-9217
Practice Address - Street 1:1545 E SOUTHLAKE BLVD
Practice Address - Street 2:ER DEPT
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6422
Practice Address - Country:US
Practice Address - Phone:817-748-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-16
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty