Provider Demographics
NPI:1104954049
Name:ADVANCED NEUROSCIENCE CLINIC, PA
Entity type:Organization
Organization Name:ADVANCED NEUROSCIENCE CLINIC, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MGR.
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGGERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-687-6203
Mailing Address - Street 1:PO BOX 4100
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79704-4100
Mailing Address - Country:US
Mailing Address - Phone:432-570-9991
Mailing Address - Fax:432-687-6299
Practice Address - Street 1:601 E 2ND ST STE E
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5435
Practice Address - Country:US
Practice Address - Phone:432-570-9991
Practice Address - Fax:432-687-6299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM38332084N0400X, 2084N0600X
TXL29142084N0600X, 2084S0012X, 2084N0400X
TXPA04008363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149225801Medicaid
TX0018HQOtherBCBS NUMBER
TX=========OtherTAX ID NUMBER