Healthcare Provider Details

I. General information

NPI: 1255883625
Provider Name (Legal Business Name): MOMENTUM ER PHYSICIANS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5011 TROUP HWY 100
TYLER TX
75707-2562
US

IV. Provider business mailing address

PO BOX 93714
SOUTHLAKE TX
76092-0116
US

V. Phone/Fax

Practice location:
  • Phone: 817-421-0034
  • Fax: 817-421-0036
Mailing address:
  • Phone: 817-421-0034
  • Fax: 817-421-0036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN BRAXTON NEIMAN
Title or Position: GENERAL COUNSEL
Credential: ESQ.
Phone: 817-421-0034