Provider Demographics
NPI:1790734515
Name:CANADIAN RIVER EMERGENCY PHYSICIANS PLLC
Entity Type:Organization
Organization Name:CANADIAN RIVER EMERGENCY PHYSICIANS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:H
Authorized Official - Last Name:GATEWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-401-2386
Mailing Address - Street 1:13737 NOEL RD
Mailing Address - Street 2:STE 1600
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1331
Mailing Address - Country:US
Mailing Address - Phone:469-401-2386
Mailing Address - Fax:214-712-2444
Practice Address - Street 1:224 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:TX
Practice Address - Zip Code:79029-3808
Practice Address - Country:US
Practice Address - Phone:806-935-7171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2013-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0097NEOtherBLUE SHIELD
TX179119601Medicaid
TX0097NEOtherBLUE SHIELD
TX=========OtherTRICARE
TX179119601Medicaid