Provider Demographics
NPI:1972679322
Name:PERINATAL MEDICINE ASSOCIATES, LLP
Entity Type:Organization
Organization Name:PERINATAL MEDICINE ASSOCIATES, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:MONROE
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-481-0111
Mailing Address - Street 1:PO BOX 100186
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76185-0186
Mailing Address - Country:US
Mailing Address - Phone:817-731-7771
Mailing Address - Fax:817-731-7774
Practice Address - Street 1:1600 W COLLEGE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3580
Practice Address - Country:US
Practice Address - Phone:817-481-0111
Practice Address - Fax:817-481-0112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0071JQOtherBCBS
TX156095502Medicaid
TX10004902OtherAMERIGROUP
TX156095501Medicaid
TX10004902OtherAMERIGROUP
TX00939VMedicare PIN