Provider Demographics
NPI:1184800955
Name:FOWLER SPORTS MEDICINE AND HEALTH PROMOTION
Entity type:Organization
Organization Name:FOWLER SPORTS MEDICINE AND HEALTH PROMOTION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-488-0885
Mailing Address - Street 1:2303 IRA E WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3926
Mailing Address - Country:US
Mailing Address - Phone:817-488-0885
Mailing Address - Fax:817-424-1234
Practice Address - Street 1:2303 IRA E WOODS AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3926
Practice Address - Country:US
Practice Address - Phone:817-488-0885
Practice Address - Fax:817-424-1234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5707302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G3940OtherBCBS
TX2903383006OtherCIGNA
TX4490907OtherAETNA
TX8756B7Medicaid
TXE23361Medicare UPIN