Basic Information
| Provider Information | |||||||||
| NPI: | 1982892105 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELITE ORTHOPAEDICS OF IRVING PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100962 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303840962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | 6153737651 | ||||||||
| Practice Location | |||||||||
| Address1: | 6750 N MACARTHUR BLVD | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750392420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144969700 | ||||||||
| FaxNumber: | 5144969707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2007 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9724018726 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 192911901 | 05 | TX | MEDICAID |