Provider Demographics
NPI:1528210663
Name:CARDIOVASCULAR CONSULTANTS OF NORTH TEXAS, LLP
Entity Type:Organization
Organization Name:CARDIOVASCULAR CONSULTANTS OF NORTH TEXAS, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETTIJOHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-800-4400
Mailing Address - Street 1:1600 W COLLEGE ST
Mailing Address - Street 2:SUITE 680
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3581
Mailing Address - Country:US
Mailing Address - Phone:817-912-8400
Mailing Address - Fax:817-912-8410
Practice Address - Street 1:1600 W COLLEGE ST
Practice Address - Street 2:SUITE 680
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3581
Practice Address - Country:US
Practice Address - Phone:817-912-8400
Practice Address - Fax:817-912-8410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149212601Medicaid
TX149212601Medicaid
TX00849RMedicare PIN