Southlake Neuromonitoring LLC

Primary specialty

Electrodiagnostic Medicine PhysicianTaxonomy code 204R00000X

Legal business name

SOUTHLAKE NEUROMONITORING LLC

Practice address

111 Boland St Ste 211
Ft Worth, TX 76107-1265

Phone

(214) 269-3875

Fax

(903) 328-6568

NPI assigned

Nov 7, 2018

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Gina Sullivan

Title

Billing Manager

Phone

(214) 269-3875

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1541548800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1541548800000",
    "number": "1982172987",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "111 BOLAND ST STE 211",
            "city": "FT WORTH",
            "state": "TX",
            "postal_code": "761071265"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 BOLAND ST STE 211",
            "city": "FT WORTH",
            "state": "TX",
            "postal_code": "761071265",
            "telephone_number": "214-269-3875",
            "fax_number": "903-328-6568"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHLAKE NEUROMONITORING LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-11-07",
        "last_updated": "2018-11-07",
        "status": "A",
        "authorized_official_last_name": "SULLIVAN",
        "authorized_official_first_name": "GINA",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "214-269-3875"
    },
    "taxonomies": [
        {
            "code": "204R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Electrodiagnostic Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Electrodiagnostic Medicine Physician in Ft Worth, TX
• Providers in Ft Worth, TX by specialty
• Electrodiagnostic Medicine Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 7, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.