Provider Demographics
NPI:1265570725
Name:TYLER PHYSICAL MEDICINE ASSOCIATES PA
Entity type:Organization
Organization Name:TYLER PHYSICAL MEDICINE ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:F HOLLEMAN
Authorized Official - Last Name:HOLLEMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:903-526-2323
Mailing Address - Street 1:2708 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5021
Mailing Address - Country:US
Mailing Address - Phone:903-526-2323
Mailing Address - Fax:903-526-2484
Practice Address - Street 1:2708 E 5TH ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5021
Practice Address - Country:US
Practice Address - Phone:903-526-2323
Practice Address - Fax:903-526-2484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-04
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6215111N00000X
TXK4082208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162882801Medicaid
00969UMedicare ID - Type Unspecified
TX162882801Medicaid