Provider Demographics
NPI:1265721401
Name:PREMIER NEPHROLOGY OF TYLER
Entity type:Organization
Organization Name:PREMIER NEPHROLOGY OF TYLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-566-2677
Mailing Address - Street 1:2702 E 5TH ST
Mailing Address - Street 2:339
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5021
Mailing Address - Country:US
Mailing Address - Phone:903-566-2677
Mailing Address - Fax:903-848-9513
Practice Address - Street 1:1304 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2262
Practice Address - Country:US
Practice Address - Phone:903-566-2677
Practice Address - Fax:903-848-9513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8527207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty