Provider Demographics
NPI:1447531876
Name:ADOLPHUS MEDICAL GROUP
Entity type:Organization
Organization Name:ADOLPHUS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-614-9180
Mailing Address - Street 1:2515 MCKINNEY AVE
Mailing Address - Street 2:SUITE 940
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-1908
Mailing Address - Country:US
Mailing Address - Phone:682-478-9117
Mailing Address - Fax:817-887-2305
Practice Address - Street 1:406 E CAMP WISDOM RD
Practice Address - Street 2:SUITE A
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75241
Practice Address - Country:US
Practice Address - Phone:682-478-9117
Practice Address - Fax:817-887-2305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty