Provider Demographics
NPI:1265594501
Name:ADVANCED MEDICAL TEAM PA
Entity type:Organization
Organization Name:ADVANCED MEDICAL TEAM PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RENSAY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:940-264-1960
Mailing Address - Street 1:2934 KEMP BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-1017
Mailing Address - Country:US
Mailing Address - Phone:940-264-1960
Mailing Address - Fax:940-264-1970
Practice Address - Street 1:2934 KEMP BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-1017
Practice Address - Country:US
Practice Address - Phone:940-264-1960
Practice Address - Fax:940-264-1970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9671111N00000X
207Q00000X
TX6286111N00000X, 111N00000X
TXJ7528208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00756WMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER