Healthcare Provider Details

I. General information

NPI: 1215670070
Provider Name (Legal Business Name): CHANNEL MEDICAL GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 03/03/2024
Certification Date: 03/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N SAINT PAUL ST STE 3100
DALLAS TX
75201-3923
US

IV. Provider business mailing address

123 5TH AVE FL 2
NEW YORK NY
10003-1019
US

V. Phone/Fax

Practice location:
  • Phone: 646-389-3451
  • Fax:
Mailing address:
  • Phone: 833-447-2775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: SABA HAQ
Title or Position: PRESIDENT
Credential: MD
Phone: 949-463-0650