Provider Demographics
NPI:1831601905
Name:BRAIN WAVES , PA
Entity type:Organization
Organization Name:BRAIN WAVES , PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:FLANAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-755-2742
Mailing Address - Street 1:2911 TURTLE CREEK BLVD STE 450
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-6290
Mailing Address - Country:US
Mailing Address - Phone:214-755-2742
Mailing Address - Fax:
Practice Address - Street 1:2911 TURTLE CREEK BLVD STE 450
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-6290
Practice Address - Country:US
Practice Address - Phone:214-755-2742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1194207L00000X, 204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty