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General NPI Number Information
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NPI Number | 1689989238
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Entity Type | Organization
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Legal Business Name | SENTINEL MEDICAL GROUP PLLC
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Dates
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Enumeration Date | 08/06/2010
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Last Update Date | 09/28/2011
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Provider Practice Location Address
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Address Line | 4706 GREENTREE BLVD
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City | MIDLAND
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State | TX
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Zip | 79707-1610
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Country | US
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Telephone | 432-218-7862
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Fax |
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Provider Business Mailing Address
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Address Line | 4706 GREENTREE BLVD
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City | MIDLAND
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State | TX
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Zip | 79707-1610
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Country | US
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Telephone | 432-218-7862
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. JACK KIM WILLIS JR.
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Credential | P.A
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Telephone | 432-218-7862
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | E7559
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA03268
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 623501
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License Number State | TX
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Taxonomy #4
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA05950
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License Number State | TX
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