Provider Demographics
NPI:1861577579
Name:EXTENDED MEDICAL MANAGEMENT SERVICES, INC.
Entity type:Organization
Organization Name:EXTENDED MEDICAL MANAGEMENT SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:469-330-2444
Mailing Address - Street 1:13140 COIT RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-5755
Mailing Address - Country:US
Mailing Address - Phone:469-330-2444
Mailing Address - Fax:469-330-2396
Practice Address - Street 1:13140 COIT RD
Practice Address - Street 2:SUITE 212
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-5755
Practice Address - Country:US
Practice Address - Phone:469-330-2444
Practice Address - Fax:469-330-2396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2309207RG0300X
TX506447363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Not Answered363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty