Provider Demographics
NPI:1720364599
Name:MEDSTREAM HEALTHCARE ASSOCIATES
Entity Type:Organization
Organization Name:MEDSTREAM HEALTHCARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DIETIKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-952-6400
Mailing Address - Street 1:1505 HARROUN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069-3433
Mailing Address - Country:US
Mailing Address - Phone:469-952-6400
Mailing Address - Fax:469-952-6410
Practice Address - Street 1:1505 HARROUN AVE STE C
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-3433
Practice Address - Country:US
Practice Address - Phone:469-952-6400
Practice Address - Fax:469-952-6410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty