Provider Demographics
NPI: | 1760700330 |
---|---|
Name: | NEUROPHYSIOLOGY |
Entity Type: | Organization |
Organization Name: | NEUROPHYSIOLOGY |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | NOLAN |
Authorized Official - Middle Name: | BRUCE |
Authorized Official - Last Name: | JENEVEIN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 214-738-4961 |
Mailing Address - Street 1: | 8122 SAN FERNANDO WAY |
Mailing Address - Street 2: | |
Mailing Address - City: | DALLAS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75218-4434 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 214-738-4961 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 6116 N CENTRAL EXPY |
Practice Address - Street 2: | SUITE 1000 |
Practice Address - City: | DALLAS |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75206-5162 |
Practice Address - Country: | US |
Practice Address - Phone: | 214-738-4961 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-05-06 |
Last Update Date: | 2010-06-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | H2492 | 2084N0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Single Specialty |