Provider Demographics
NPI:1194765586
Name:LONESTAR PROVIDER NETWORK
Entity type:Organization
Organization Name:LONESTAR PROVIDER NETWORK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-566-6000
Mailing Address - Street 1:PO BOX 404390
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-4390
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:615-373-7651
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:SUITE C-300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-6000
Practice Address - Fax:972-566-6237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0092LTOtherBCBS OF TX (AUSTIN)
TX0092LTOtherBCBS OF TX (AUSTIN)