Provider Demographics
NPI:1336425289
Name:SALLY A HALLGREN, D.O., P.A.
Entity Type:Organization
Organization Name:SALLY A HALLGREN, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-877-4787
Mailing Address - Street 1:311 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-1924
Mailing Address - Country:US
Mailing Address - Phone:817-877-4787
Mailing Address - Fax:817-877-1654
Practice Address - Street 1:311 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-1924
Practice Address - Country:US
Practice Address - Phone:817-877-4787
Practice Address - Fax:817-877-1654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9484208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD97364Medicare UPIN