Provider Demographics
NPI:1902187701
Name:SHANE T SEROYER MD PA
Entity Type:Organization
Organization Name:SHANE T SEROYER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SEROYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-419-0303
Mailing Address - Street 1:515 W MAYFIELD RD STE 116
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-2084
Mailing Address - Country:US
Mailing Address - Phone:817-419-0303
Mailing Address - Fax:817-468-5963
Practice Address - Street 1:515 W MAYFIELD RD STE 116
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2084
Practice Address - Country:US
Practice Address - Phone:817-419-0303
Practice Address - Fax:817-468-5963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1887207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204613801Medicaid