Provider Demographics
NPI:1235135906
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:972-860-8649
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:972-860-8648
Mailing Address - Fax:972-860-8679
Practice Address - Street 1:5232 COLLEYVILLE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-7826
Practice Address - Country:US
Practice Address - Phone:817-498-9920
Practice Address - Fax:817-498-0635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00T04Z207Q00000X, 207R00000X, 207RG0100X, 207RI0008X, 207RR0500X, 2084N0400X, 208600000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatologyGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T04ZOtherBCBS
TX0851099-02Medicaid
TX00T04ZMedicare PIN
TXCI8938Medicare PIN
TXCJ5623Medicare PIN
TX00T04ZOtherBCBS