Provider Demographics
NPI:1437668951
Name:LONE STAR PROGRESSIVE MEDICINE OF BURLESON PA
Entity type:Organization
Organization Name:LONE STAR PROGRESSIVE MEDICINE OF BURLESON PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:PETTKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-297-7100
Mailing Address - Street 1:1320 NW JOHN JONES DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-8040
Mailing Address - Country:US
Mailing Address - Phone:817-297-7100
Mailing Address - Fax:
Practice Address - Street 1:1320 NW JOHN JONES DR
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-8040
Practice Address - Country:US
Practice Address - Phone:817-297-7100
Practice Address - Fax:817-297-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty