Provider Demographics
NPI:1356506752
Name:LEGACY HEART CARE OF FORT WORTH LLC
Entity Type:Organization
Organization Name:LEGACY HEART CARE OF FORT WORTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRATCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-423-4400
Mailing Address - Street 1:2500 WEST FWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-5848
Mailing Address - Country:US
Mailing Address - Phone:817-423-4400
Mailing Address - Fax:817-423-8080
Practice Address - Street 1:2500 WEST FWY
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5848
Practice Address - Country:US
Practice Address - Phone:817-423-4400
Practice Address - Fax:817-423-8080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RC0000X
TXPA02558363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty