Provider Demographics
NPI:1689989238
Name:SENTINEL MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:SENTINEL MEDICAL GROUP PLLC
Other - Org Name:THE CLINIC AT GREENTREE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PA
Authorized Official - Phone:432-218-7862
Mailing Address - Street 1:4706 GREENTREE BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-1610
Mailing Address - Country:US
Mailing Address - Phone:432-218-7862
Mailing Address - Fax:
Practice Address - Street 1:4706 GREENTREE BLVD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-1610
Practice Address - Country:US
Practice Address - Phone:432-218-7862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-06
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7559207R00000X
TXPA05950363AM0700X
TXPA03268363AM0700X
TX623501363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty