Healthcare Provider Details

I. General information

NPI: 1871514679
Provider Name (Legal Business Name): SPORTS & ORTHOPAEDIC GROUP OF DALLAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 SNIDER PLZ STE 200
DALLAS TX
75205-5651
US

IV. Provider business mailing address

6901 SNIDER PLZ STE 200
DALLAS TX
75205-5651
US

V. Phone/Fax

Practice location:
  • Phone: 214-369-7733
  • Fax: 214-369-7739
Mailing address:
  • Phone: 214-369-7733
  • Fax: 214-369-7739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: MS. SHELLEY D. COOLEY
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 214-369-7733