Provider Demographics
NPI:1639312895
Name:SURGICAL RESOLUTIONS PLLC
Entity Type:Organization
Organization Name:SURGICAL RESOLUTIONS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:NIBLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-283-2244
Mailing Address - Street 1:921 YORK DR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2043
Mailing Address - Country:US
Mailing Address - Phone:972-283-2244
Mailing Address - Fax:972-283-2246
Practice Address - Street 1:921 YORK DR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2043
Practice Address - Country:US
Practice Address - Phone:972-283-2244
Practice Address - Fax:972-283-2246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3706208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105633503Medicaid
TX105633503Medicaid
TX0A3983Medicare PIN