Provider Demographics
NPI:1972658680
Name:SOUTHWEST DALLAS ORTHOPEDIC ASST PA
Entity Type:Organization
Organization Name:SOUTHWEST DALLAS ORTHOPEDIC ASST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-333-9175
Mailing Address - Street 1:PO BOX 381329
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75138-1329
Mailing Address - Country:US
Mailing Address - Phone:214-333-9175
Mailing Address - Fax:214-330-4609
Practice Address - Street 1:2909 SOUTH HAMPTON
Practice Address - Street 2:SUITE D107
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224
Practice Address - Country:US
Practice Address - Phone:214-333-9175
Practice Address - Fax:214-330-4609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175763502Medicaid
TX00196YMedicare PIN