Provider Demographics
NPI:1316439201
Name:ENNIS PHYSICAL MEDICINE, PLLC
Entity type:Organization
Organization Name:ENNIS PHYSICAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CAMERON
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-293-9355
Mailing Address - Street 1:109 NW MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-4079
Mailing Address - Country:US
Mailing Address - Phone:972-293-9355
Mailing Address - Fax:
Practice Address - Street 1:109 NW MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-4079
Practice Address - Country:US
Practice Address - Phone:972-293-9355
Practice Address - Fax:915-206-5076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5597208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty