Provider Demographics
NPI:1831811918
Name:SUNDANCE PHYSICAL MEDICINE PLLC
Entity type:Organization
Organization Name:SUNDANCE PHYSICAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUDET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-462-9729
Mailing Address - Street 1:3829 CATHEDRAL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-3871
Mailing Address - Country:US
Mailing Address - Phone:337-255-7011
Mailing Address - Fax:
Practice Address - Street 1:1400 W 7TH ST STE 450
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-2601
Practice Address - Country:US
Practice Address - Phone:817-935-8200
Practice Address - Fax:817-887-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty