Provider Demographics
NPI:1184886640
Name:SUSAN R. BAILEY, M.D.P.A.
Entity type:Organization
Organization Name:SUSAN R. BAILEY, M.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-315-2550
Mailing Address - Street 1:5929 LOVELL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5029
Mailing Address - Country:US
Mailing Address - Phone:817-315-2550
Mailing Address - Fax:817-732-4660
Practice Address - Street 1:5929 LOVELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5029
Practice Address - Country:US
Practice Address - Phone:817-315-2550
Practice Address - Fax:817-732-4660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0037261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032156401Medicaid
TX032156401Medicaid
TXD87498Medicare UPIN