Provider Demographics
NPI:1194781773
Name:NORTH CENTRAL TEXAS ORTHOPAEDICS AND SPORTS MEDICINE PA
Entity type:Organization
Organization Name:NORTH CENTRAL TEXAS ORTHOPAEDICS AND SPORTS MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:940-627-3491
Mailing Address - Street 1:2800 E TX HWY 114
Mailing Address - Street 2:STE 130
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262
Mailing Address - Country:US
Mailing Address - Phone:469-916-4435
Mailing Address - Fax:855-959-1785
Practice Address - Street 1:2800 E TX HIGHWAY 114 STE 130
Practice Address - Street 2:
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262-5305
Practice Address - Country:US
Practice Address - Phone:469-916-4435
Practice Address - Fax:855-959-1785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0118207X00000X, 261QP2000X
TXK7089207X00000X
207XX0005X, 261QM1300X
TXM6477208100000X
TX1305213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1141880001OtherDME
TX080630901Medicaid
TX89Z590OtherBCBS
TX080630901Medicaid