Provider Demographics
NPI:1720031370
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 1:3600 GASTON AVE
Mailing Address - Street 2:SUITE 1205
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-692-8262
Mailing Address - Fax:214-696-4190
Practice Address - Street 1:8230 WALNUT HILL LN
Practice Address - Street 2:SUITE 700
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4482
Practice Address - Country:US
Practice Address - Phone:214-691-1902
Practice Address - Fax:214-987-1845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK32322085R0001X
TXM0918208800000X
TXG93452088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119844205Medicaid
TX119844204Medicaid
TXCI6342OtherRR MEDICARE GROUP
0036DEOtherBCBS GROUP
TX119844203Medicaid
TXTXB134139Medicare PIN
PA260493Medicare PIN
TX119844204Medicaid
TX00489KMedicare PIN
TX00119XMedicare PIN