Provider Demographics
NPI:1841225919
Name:HEALTHTEXAS PROVIDER NETWORK
Entity Type:Organization
Organization Name:HEALTHTEXAS PROVIDER NETWORK
Other - Org Name:PHYSIATRIC MEDICINE ASSOCIATES
Other - Org Type:Doing Business As
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:SUITE 1650
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-1838
Mailing Address - Country:US
Mailing Address - Phone:972-860-8648
Mailing Address - Fax:972-860-8679
Practice Address - Street 1:1643 LANCASTER DR
Practice Address - Street 2:SUITE 101A
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3593
Practice Address - Country:US
Practice Address - Phone:817-424-4151
Practice Address - Fax:817-424-4181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T89ZOtherBCBS
TX00T89ZOtherBCBS