Provider Demographics
NPI:1487077111
Name:PHYCARE SERVICES INC
Entity type:Organization
Organization Name:PHYCARE SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROOSEVELT
Authorized Official - Middle Name:
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:817-526-2882
Mailing Address - Street 1:2201 MAIN ST
Mailing Address - Street 2:1225
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2201 MAIN ST
Practice Address - Street 2:1225
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-4327
Practice Address - Country:US
Practice Address - Phone:817-526-2882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG37993208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty