Provider Demographics
NPI:1952623860
Name:DR. ROOSEVELT TAYLOR JR PA
Entity type:Organization
Organization Name:DR. ROOSEVELT TAYLOR JR PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROOSEVELT
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:214-391-3700
Mailing Address - Street 1:9209 ELAM RD STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-7360
Mailing Address - Country:US
Mailing Address - Phone:214-391-3700
Mailing Address - Fax:
Practice Address - Street 1:9209 ELAM RD STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-7360
Practice Address - Country:US
Practice Address - Phone:214-391-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9896207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121397702Medicaid
TX10029783OtherMEDICAID AMERIGOUP HMO
TX10029783OtherMEDICAID AMERIGOUP HMO