Provider Demographics
NPI:1265503957
Name:WEST PARK CLINIC
Entity Type:Organization
Organization Name:WEST PARK CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-277-4441
Mailing Address - Street 1:912 WRIGHT ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-4759
Mailing Address - Country:US
Mailing Address - Phone:817-277-4441
Mailing Address - Fax:
Practice Address - Street 1:1106 W RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-6506
Practice Address - Country:US
Practice Address - Phone:817-277-4441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-1289579OtherTAX IDENTIFICATION NUMBER
TX0001GFOtherBLUE CROSS BLUE SHIELD TX
TX082969901Medicaid
TX75-1289579OtherTAX IDENTIFICATION NUMBER