Basic Information
| Provider Information | |||||||||
| NPI: | 1730584194 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARCHERFISH ACUTE TRAUMA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13737 NOEL RD | ||||||||
| Address2: | STE 1600 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752401331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4694012386 | ||||||||
| FaxNumber: | 2147122444 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 MAR WALT DR | ||||||||
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| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508621111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2014 | ||||||||
| LastUpdateDate: | 10/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | BRYNE | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4694012386 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.