Provider Demographics
NPI:1972707917
Name:PARK LANE MEDICAL GROUP P.A.
Entity Type:Organization
Organization Name:PARK LANE MEDICAL GROUP P.A.
Other - Org Name:GRANT P. BECKHAM, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:P
Authorized Official - Last Name:BECKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-361-7000
Mailing Address - Street 1:9101 N. CENTRAL EXPRESSWAY
Mailing Address - Street 2:SUITE 350
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231
Mailing Address - Country:US
Mailing Address - Phone:214-361-7000
Mailing Address - Fax:214-361-7675
Practice Address - Street 1:9101 N. CENTRAL EXPRESSWAY
Practice Address - Street 2:SUITE 350
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231
Practice Address - Country:US
Practice Address - Phone:214-361-7000
Practice Address - Fax:214-361-7675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1870207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF90860Medicare UPIN