Provider Demographics
NPI:1831249499
Name:SOUTHWEST REGIONAL ORTHOPEDIC SPORTS MEDICINE
Entity type:Organization
Organization Name:SOUTHWEST REGIONAL ORTHOPEDIC SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-333-9175
Mailing Address - Street 1:PO BOX 381329
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75165
Mailing Address - Country:US
Mailing Address - Phone:972-923-3800
Mailing Address - Fax:972-351-9360
Practice Address - Street 1:1505 W JEFFERSON
Practice Address - Street 2:SUITE 102
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165
Practice Address - Country:US
Practice Address - Phone:972-923-3800
Practice Address - Fax:972-351-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1757635201Medicaid
TX1757635203Medicaid
TX00197YMedicare PIN