Healthcare Provider Details

I. General information

NPI: 1326108200
Provider Name (Legal Business Name): IMMANUEL BRAIN, SPINE AND NERVE SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 03/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 MATLOCK CENTRE CIR
ARLINGTON TX
76015-2536
US

IV. Provider business mailing address

624 MATLOCK CENTRE CIR
ARLINGTON TX
76015-2536
US

V. Phone/Fax

Practice location:
  • Phone: 817-795-7337
  • Fax: 817-795-8393
Mailing address:
  • Phone: 817-795-7337
  • Fax: 817-795-8393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberJ2368
License Number StateTX

VIII. Authorized Official

Name: DR. KEVIN R. TEAL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 817-795-7337