Provider Demographics
NPI:1710219795
Name:FORT WORTH PEDIATRICS
Entity Type:Organization
Organization Name:FORT WORTH PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-336-4040
Mailing Address - Street 1:1108 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4430
Mailing Address - Country:US
Mailing Address - Phone:817-335-3255
Mailing Address - Fax:817-338-9563
Practice Address - Street 1:1108 S HENDERSON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4430
Practice Address - Country:US
Practice Address - Phone:817-335-3255
Practice Address - Fax:817-338-9563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130900703Medicaid