Provider Demographics
NPI:1851668149
Name:PEDIATRIC URGENT CARE CENTER OF FORT WORTH, P.A..
Entity Type:Organization
Organization Name:PEDIATRIC URGENT CARE CENTER OF FORT WORTH, P.A..
Other - Org Name:FORT WORTH CONCIERGE PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:COWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-271-4309
Mailing Address - Street 1:3701 VISION DR STE 103
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-1184
Mailing Address - Country:US
Mailing Address - Phone:817-259-2365
Mailing Address - Fax:817-259-2366
Practice Address - Street 1:3701 VISION DR STE 103
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-1184
Practice Address - Country:US
Practice Address - Phone:817-259-2365
Practice Address - Fax:817-259-2366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9459207PP0204X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX313997401Medicaid