Provider Demographics
NPI:1215279146
Name:GNC MEDICAL, PA
Entity type:Organization
Organization Name:GNC MEDICAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:972-494-3100
Mailing Address - Street 1:5500 DEMOCRACY DR.
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024
Mailing Address - Country:US
Mailing Address - Phone:972-494-3100
Mailing Address - Fax:972-608-0005
Practice Address - Street 1:5500 DEMOCRACY DR.
Practice Address - Street 2:SUITE 150
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024
Practice Address - Country:US
Practice Address - Phone:972-494-3100
Practice Address - Fax:972-608-0005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GNC MEDICAL, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-18
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X
TX207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty