Healthcare Provider Details

I. General information

NPI: 1487029880
Provider Name (Legal Business Name): SAMANTHA BIRTALAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E SOUTHLAKE BLVD SUITE 150
SOUTHLAKE TX
76092-6269
US

IV. Provider business mailing address

251 E SOUTHLAKE BLVD SUITE 150
SOUTHLAKE TX
76092-6269
US

V. Phone/Fax

Practice location:
  • Phone: 817-424-0971
  • Fax: 888-866-4929
Mailing address:
  • Phone: 817-424-0971
  • Fax: 888-866-4929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: