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NPI Code Detail

MEDICARE: BLUEJACK SURGICAL AFFILIATES

MEDICARE: BLUEJACK SURGICAL AFFILIATES
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AS0400XSurgical Physician Assistant

General Provider Information

NPI Number : 1043869100
Entity Type Code : Organization
Provider Name (Legal Business Name) : BLUEJACK SURGICAL AFFILIATES
Provider Business Mailing Address
First Line : 1202 E ARAPAHO RD STE 122
Second Line :
City : RICHARDSON
State : TX
Zip : 75081-2400
Country : US
Telephone Number : 469-250-4422
Fax Number : 469-250-7068
Provider Business Practice Location Address
First Line : 1202 E ARAPAHO RD STE 122
Second Line :
City : RICHARDSON
State : TX
Zip : 75081-2400
Country : US
Telephone Number : 469-250-4422
Fax Number : 469-250-7068
Authorized Official
Title or Position : MANAGING PARTNER
Name : CHRISTOPHER JOHN BROCK
Credential :
Telephone Number : 972-979-6222
Provider Enumeration Date : 09/10/2019
Last Update Date : 09/10/2019

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Directions to “BLUEJACK SURGICAL AFFILIATES ” Practice Location

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