Provider Demographics
NPI:1205831823
Name:HEALTHTEXAS PROVIDER NETWORK - PHYSIATRIC MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:HEALTHTEXAS PROVIDER NETWORK - PHYSIATRIC MEDICINE ASSOCIATES
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:972-860-8649
Mailing Address - Street 1:8080 N CENTRAL EXPY, LB 82
Mailing Address - Street 2:STE 1650
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-3789
Mailing Address - Country:US
Mailing Address - Phone:972-860-8653
Mailing Address - Fax:972-860-8679
Practice Address - Street 1:507 N HIGHWAY 77
Practice Address - Street 2:STE 700
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-1889
Practice Address - Country:US
Practice Address - Phone:972-923-2738
Practice Address - Fax:972-935-9230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0016AH208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T89ZOtherBCBS
TX0016AHMedicare PIN