Provider Demographics
NPI:1215260559
Name:PROVIDER SERVICES OF TEXAS LLC
Entity type:Organization
Organization Name:PROVIDER SERVICES OF TEXAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:JERNBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-712-2000
Mailing Address - Street 1:13737 NOEL RD
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1331
Mailing Address - Country:US
Mailing Address - Phone:214-712-2074
Mailing Address - Fax:214-712-2487
Practice Address - Street 1:100A E ALTON GLOOR BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-3375
Practice Address - Country:US
Practice Address - Phone:956-350-7000
Practice Address - Fax:214-712-2487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-17
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty