Provider Demographics
NPI:1265719140
Name:PREMIER GASTROENTEROLOGY OF TEXAS PA
Entity type:Organization
Organization Name:PREMIER GASTROENTEROLOGY OF TEXAS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMIEN
Authorized Official - Middle Name:BASSAM
Authorized Official - Last Name:MALLAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-566-5266
Mailing Address - Street 1:7777 FOREST LANE BLDG. C
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2513
Mailing Address - Country:US
Mailing Address - Phone:972-566-5266
Mailing Address - Fax:972-566-5245
Practice Address - Street 1:7777 FOREST LANE BLDG. C
Practice Address - Street 2:SUITE 204
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2513
Practice Address - Country:US
Practice Address - Phone:972-566-5266
Practice Address - Fax:972-566-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-07
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0393207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty