Provider Demographics
NPI:1649468059
Name:GREENVILLE NEUROLOGY ASSOC, MD PA
Entity type:Organization
Organization Name:GREENVILLE NEUROLOGY ASSOC, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAMIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-618-0808
Mailing Address - Street 1:4501 JOE RAMSEY BLVD E STE 200
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-7842
Mailing Address - Country:US
Mailing Address - Phone:903-450-8122
Mailing Address - Fax:903-454-2785
Practice Address - Street 1:5550 WARREN PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-7399
Practice Address - Country:US
Practice Address - Phone:214-618-0808
Practice Address - Fax:469-200-8097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK79812084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1767444Medicaid
TX1767444Medicaid
TX00886YMedicare PIN