Provider Demographics
NPI:1033560222
Name:FORTWORTH RENAL GROUP PA
Entity Type:Organization
Organization Name:FORTWORTH RENAL GROUP PA
Other - Org Name:KIDNEY AND HYPERTENSION SPECIALISTS OF FORT WORTH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OLADAPO
Authorized Official - Middle Name:
Authorized Official - Last Name:AFOLABI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-360-6081
Mailing Address - Street 1:1902 WINDSOR PL STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1866
Mailing Address - Country:US
Mailing Address - Phone:682-207-1700
Mailing Address - Fax:682-250-5246
Practice Address - Street 1:1902 WINDSOR PL STE 102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1866
Practice Address - Country:US
Practice Address - Phone:682-207-1700
Practice Address - Fax:682-250-5246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-28
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1033560222Medicaid
TX1114918356OtherNPI
TX1588656391OtherNPI
TXH41302Medicare UPIN