Provider Demographics
NPI:1891090155
Name:C M PERSONS M D P A
Entity Type:Organization
Organization Name:C M PERSONS M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:PERSONS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNFA
Authorized Official - Phone:817-399-1622
Mailing Address - Street 1:4625 BOAT CLUB RD.
Mailing Address - Street 2:STE: 253
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-7023
Mailing Address - Country:US
Mailing Address - Phone:817-399-1622
Mailing Address - Fax:817-540-0759
Practice Address - Street 1:4625 BOAT CLUB RD
Practice Address - Street 2:STE: 253
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-7022
Practice Address - Country:US
Practice Address - Phone:817-399-1622
Practice Address - Fax:817-540-0759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4368207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114261403Medicaid
TX114261403Medicaid
TX1035650001Medicare NSC
TXC20436Medicare UPIN