Provider Demographics
NPI:1134545924
Name:INTELLIMEDICINE, PA
Entity type:Organization
Organization Name:INTELLIMEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TYROCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-532-5858
Mailing Address - Street 1:5823 N MESA ST # 537
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-4607
Mailing Address - Country:US
Mailing Address - Phone:915-261-4377
Mailing Address - Fax:915-532-5859
Practice Address - Street 1:154 NORTH FESTIVAL DRIVE, VILLA F
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-6184
Practice Address - Country:US
Practice Address - Phone:915-532-5858
Practice Address - Fax:915-532-5859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1945207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK1945OtherTX MED LIC