Provider Demographics
NPI:1063417699
Name:HEALTHTEXAS PROVIDER NETWORK
Entity type:Organization
Organization Name:HEALTHTEXAS PROVIDER NETWORK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:FOURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-860-8649
Mailing Address - Street 1:8080 N CENTRAL EXPY
Mailing Address - Street 2:STE 600, LB82
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-1838
Mailing Address - Country:US
Mailing Address - Phone:972-860-8648
Mailing Address - Fax:972-860-8679
Practice Address - Street 1:200 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160-2732
Practice Address - Country:US
Practice Address - Phone:972-551-7500
Practice Address - Fax:972-524-7418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00249N208000000X, 207R00000X, 207RP1001X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0802258-01Medicaid
TX00249NOtherBCBSTX
TX0802258-01Medicaid
TX00249NMedicare PIN