Provider Demographics
NPI:1841662087
Name:GAINSVILLE ALLERGY, ENT AND PLASTIC SURGERY
Entity type:Organization
Organization Name:GAINSVILLE ALLERGY, ENT AND PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:940-612-8764
Mailing Address - Street 1:1902 HOSPITAL BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-2008
Mailing Address - Country:US
Mailing Address - Phone:940-612-8850
Mailing Address - Fax:940-612-8856
Practice Address - Street 1:1902 HOSPITAL BLVD STE C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-2008
Practice Address - Country:US
Practice Address - Phone:940-612-8850
Practice Address - Fax:940-612-8856
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GAINSVILLE HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-27
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QM2500X
261QR1300X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX313274801Medicaid
TX313274801Medicaid
TXB163081Medicare PIN