Basic Information
Provider Information | |||||||||
NPI: | 1902187701 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHANE T SEROYER MD PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 515 W MAYFIELD RD STE 116 | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON | ||||||||
State: | TX | ||||||||
PostalCode: | 760142084 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8174190303 | ||||||||
FaxNumber: | 8174685963 | ||||||||
Practice Location | |||||||||
Address1: | 515 W MAYFIELD RD STE 116 | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON | ||||||||
State: | TX | ||||||||
PostalCode: | 760142084 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8174190303 | ||||||||
FaxNumber: | 8174685963 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2011 | ||||||||
LastUpdateDate: | 09/07/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SEROYER | ||||||||
AuthorizedOfficialFirstName: | SHANE | ||||||||
AuthorizedOfficialMiddleName: | THOMAS | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8174190303 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | N1887 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 204613801 | 05 | TX |   | MEDICAID |