Provider Demographics
NPI:1972046209
Name:SOM PHYSICIAN ASSOCIATES PLLC
Entity Type:Organization
Organization Name:SOM PHYSICIAN ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAMSIDEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-552-7426
Mailing Address - Street 1:4237 CRESTFIELD DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-5301
Mailing Address - Country:US
Mailing Address - Phone:773-552-7426
Mailing Address - Fax:
Practice Address - Street 1:4716 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-3836
Practice Address - Country:US
Practice Address - Phone:817-413-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4477208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty