Provider Demographics
NPI:1760411847
Name:SOUTHERN NEURO REHAB INSTITIUTE, PLLC
Entity Type:Organization
Organization Name:SOUTHERN NEURO REHAB INSTITIUTE, PLLC
Other - Org Name:SOUTHERN NEURO REHAB INSTITIUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHIUFANG
Authorized Official - Middle Name:
Authorized Official - Last Name:HWANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-572-4000
Mailing Address - Street 1:3430 W WHEATLAND RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3446
Mailing Address - Country:US
Mailing Address - Phone:972-572-4000
Mailing Address - Fax:972-572-3992
Practice Address - Street 1:3430 W WHEATLAND RD
Practice Address - Street 2:SUITE 107
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3446
Practice Address - Country:US
Practice Address - Phone:972-572-4000
Practice Address - Fax:972-572-3992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0839208100000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162297901Medicaid
TX0082KPOtherBLUE CROSS BLUE SHIELD TX
TX0082KPOtherBLUE CROSS BLUE SHIELD TX
TX00859VMedicare ID - Type Unspecified