Provider Demographics
NPI: | 1760488936 |
---|---|
Name: | HEALTHTEXAS PROVIDER NETWORK |
Entity Type: | Organization |
Organization Name: | HEALTHTEXAS PROVIDER NETWORK |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DIRECTOR |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | ELLEN |
Authorized Official - Middle Name: | ELIZABETH |
Authorized Official - Last Name: | FOURTON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 972-860-8649 |
Mailing Address - Street 1: | 8080 N CENTRAL EXPY |
Mailing Address - Street 2: | STE 600, LB82 |
Mailing Address - City: | DALLAS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75206-3794 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 972-860-8648 |
Mailing Address - Fax: | 972-860-8679 |
Practice Address - Street 1: | 3600 GASTON AVE |
Practice Address - Street 2: | STE 656 |
Practice Address - City: | DALLAS |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75246-1906 |
Practice Address - Country: | US |
Practice Address - Phone: | 214-820-3466 |
Practice Address - Fax: | 214-820-3468 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-06-22 |
Last Update Date: | 2015-08-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 00N85X | 207N00000X, 207Q00000X, 207QH0002X, 207R00000X, 207RC0000X, 207RE0101X, 207RG0100X, 207RI0008X, 207RR0500X, 207V00000X, 208000000X, 208100000X, 2084N0400X, 208600000X, 208M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
No | 207QH0002X | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | Group - Multi-Specialty |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RI0008X | Allopathic & Osteopathic Physicians | Internal Medicine | Hepatology | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 084328609 | Medicaid | |
TX | 00N85X | Other | BCBS |
TX | 0843286-01 | Medicaid | |
TX | 0844300001 | Medicare NSC | |
TX | 0844300007 | Medicare NSC | |
TX | 00N85X | Other | BCBS |
TX | CD6866 | Medicare PIN | |
TX | 00N85X | Medicare PIN |