Provider Demographics
NPI:1144511353
Name:MASS EFFECT MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:MASS EFFECT MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERIF
Authorized Official - Middle Name:M
Authorized Official - Last Name:LATIF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-250-7440
Mailing Address - Street 1:12015 QUINCY LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2121
Mailing Address - Country:US
Mailing Address - Phone:940-202-0789
Mailing Address - Fax:940-241-4022
Practice Address - Street 1:401 AME DR
Practice Address - Street 2:APT 1103
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76207
Practice Address - Country:US
Practice Address - Phone:214-260-7745
Practice Address - Fax:877-442-9313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2620207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144511353OtherGRP NPI