Provider Demographics
NPI:1013559707
Name:BLACK ACRE EMERGENCY PHYSICIANS MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:BLACK ACRE EMERGENCY PHYSICIANS MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-451-4208
Mailing Address - Street 1:PO BOX 8292
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-0292
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:817-563-3699
Practice Address - Street 1:100 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78738-5621
Practice Address - Country:US
Practice Address - Phone:817-451-4208
Practice Address - Fax:817-563-3699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty