Provider Demographics
NPI:1659621035
Name:UROLOGY CLINICS OF NORTH TEXAS PLLC
Entity Type:Organization
Organization Name:UROLOGY CLINICS OF NORTH TEXAS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRI
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-691-1902
Mailing Address - Street 1:7515 GREENVILLE AVE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-3831
Mailing Address - Country:US
Mailing Address - Phone:214-691-1902
Mailing Address - Fax:214-853-9415
Practice Address - Street 1:100 KESTREL DR
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-2060
Practice Address - Country:US
Practice Address - Phone:610-831-5354
Practice Address - Fax:214-853-9415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0918208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00489KMedicare PIN