Provider Demographics
NPI:1194776872
Name:METROPLEX MEDICAL REHABILITATION & SPORTS MEDICINE PA
Entity type:Organization
Organization Name:METROPLEX MEDICAL REHABILITATION & SPORTS MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-284-9850
Mailing Address - Street 1:PO BOX 678596
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8595
Mailing Address - Country:US
Mailing Address - Phone:817-423-9054
Mailing Address - Fax:817-423-9719
Practice Address - Street 1:6116 OAKBEND TRL
Practice Address - Street 2:SUITE 112
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3925
Practice Address - Country:US
Practice Address - Phone:817-423-9054
Practice Address - Fax:817-423-9719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5755208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0033DVOtherBCBS
TX178029801Medicaid
0030PXOtherBCBS
TX0033DVOtherBCBS GROUP NUMBER
TX00740XMedicare PIN
TXDP3820Medicare PIN
0030PXOtherBCBS
TX00740XMedicare ID - Type Unspecified