Basic Information
| Provider Information | |||||||||
| NPI: | 1083788848 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROASSIST SURGICAL ASSOCIATES, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROASSIST BILLING SOLUTIONS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2150 S CENTRAL EXPY | ||||||||
| Address2: | STE 130 | ||||||||
| City: | MCKINNEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750704070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723638200 | ||||||||
| FaxNumber: | 9723638196 | ||||||||
| Practice Location | |||||||||
| Address1: | 2150 S CENTRAL EXPY | ||||||||
| Address2: | STE 130 | ||||||||
| City: | MCKINNEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750704070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723638200 | ||||||||
| FaxNumber: | 9723638196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 02/10/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FULLER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9723638200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PA-C | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | CERT 82396 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | 412217629 | 01 | TX | OLD TAX ID | OTHER | 613033500 | 01 | TX | DOL | OTHER | 0062PC | 01 | TX | BCBS | OTHER |