Provider Demographics
NPI:1063741221
Name:IDEM, EMEM (MD)
Entity type:Individual
Prefix:
First Name:EMEM
Middle Name:
Last Name:IDEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:800-994-0371
Mailing Address - Fax:
Practice Address - Street 1:2600 E PFLUGERVILLE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-5999
Practice Address - Country:US
Practice Address - Phone:512-654-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-17
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9372207R00000X
IDM-14551208M00000X
OH57.015818207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX341747904Medicaid
TX341747905Medicaid
TX341747902Medicaid
TX341747903Medicaid
TX373078YKXYOtherMEDICARE
TX373078YLP1OtherMEDICARE
TX373078YLP2OtherMEDICARE
TX373078YKXVOtherMEDICARE