Healthcare Provider Details

I. General information

NPI: 1932786290
Provider Name (Legal Business Name): PBH PROFESSIONAL GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2219 W EULESS BLVD STE 100
EULESS TX
76040-6624
US

IV. Provider business mailing address

103 POWELL CT STE 100
BRENTWOOD TN
37027-5050
US

V. Phone/Fax

Practice location:
  • Phone: 817-857-9110
  • Fax: 817-391-3262
Mailing address:
  • Phone: 615-308-7871
  • Fax: 615-261-8901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: FLORA F. SADRI-AZARBAYEJANI
Title or Position: PRESIDENT AND SECRETARY
Credential: D.O.
Phone: 615-308-7871