Provider Demographics
NPI:1811025117
Name:CLINICAL NEPHROLOGY ASSOCIATES, PA
Entity Type:Organization
Organization Name:CLINICAL NEPHROLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:O
Authorized Official - Last Name:GRATCH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-927-2612
Mailing Address - Street 1:PO BOX 470787
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76147-0787
Mailing Address - Country:US
Mailing Address - Phone:817-923-8050
Mailing Address - Fax:817-923-8832
Practice Address - Street 1:920 SANTA FE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5864
Practice Address - Country:US
Practice Address - Phone:817-923-8050
Practice Address - Fax:817-923-8832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085155203Medicaid
TX00209WOtherBCBS OF TEXAS
TXCT1051OtherMEDICARE RAILROAD
TX085155203Medicaid