Provider Demographics
NPI:1578686127
Name:UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER AT FORT WORTH
Entity Type:Organization
Organization Name:UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER AT FORT WORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-735-2008
Mailing Address - Street 1:3500 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2644
Mailing Address - Country:US
Mailing Address - Phone:817-735-2000
Mailing Address - Fax:
Practice Address - Street 1:3500 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-735-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER AT FORT WORTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-09
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140691001Medicaid