Provider Demographics
NPI:1407808652
Name:FORT WORTH PEDIATRICS
Entity Type:Organization
Organization Name:FORT WORTH PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RICHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-336-4040
Mailing Address - Street 1:5708 EDWARDS RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109
Mailing Address - Country:US
Mailing Address - Phone:817-336-4040
Mailing Address - Fax:817-336-6780
Practice Address - Street 1:5708 EDWARDS RANCH ROAD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109
Practice Address - Country:US
Practice Address - Phone:817-336-4040
Practice Address - Fax:817-336-6780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8541908OtherAETNA
TX130900702Medicaid
TX10001409OtherAMERIGROUP
TX00L72LOtherBCBS
TX130900703Medicaid
TX130900704Medicaid