Healthcare Provider Details

I. General information

NPI: 1083089726
Provider Name (Legal Business Name): MEDICAL COMMAND CLINICAL PRACTICE OF PENNSYLVANIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 12/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13737 NOEL RD SUITE 1400
DALLAS TX
75240-1331
US

IV. Provider business mailing address

PO BOX 785186
PHILADELPHIA PA
19178-5186
US

V. Phone/Fax

Practice location:
  • Phone: 214-712-2815
  • Fax: 888-491-7218
Mailing address:
  • Phone: 214-712-2815
  • Fax: 888-491-7218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State

VIII. Authorized Official

Name: RUSSELL HARRIS
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 214-754-8700