Provider Demographics
NPI:1003811639
Name:HEALTHTEXAS PROVIDER NETWORK
Entity Type:Organization
Organization Name:HEALTHTEXAS PROVIDER NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:FOURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-800-8649
Mailing Address - Street 1:8080 N CENTRAL EXPY
Mailing Address - Street 2:STE 600, LB82
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-3794
Mailing Address - Country:US
Mailing Address - Phone:469-800-8648
Mailing Address - Fax:469-800-8679
Practice Address - Street 1:5575 WARREN PKWY
Practice Address - Street 2:STE. 115
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-4062
Practice Address - Country:US
Practice Address - Phone:972-712-3652
Practice Address - Fax:214-618-3614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00348T207Q00000X, 207V00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1516171-02Medicaid
TX0092HQOtherBCBSTX
TX00348TMedicare PIN
TX0844300006Medicare NSC
TXCD6866Medicare PIN
TX0844300008Medicare NSC
TXCC6759Medicare PIN