Provider Demographics
NPI:1598856551
Name:AMBASSADOR PHYSICIAN GROUP LLC
Entity type:Organization
Organization Name:AMBASSADOR PHYSICIAN GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-975-4539
Mailing Address - Street 1:6100 HARRIS PKWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4101
Mailing Address - Country:US
Mailing Address - Phone:817-433-5179
Mailing Address - Fax:817-433-5177
Practice Address - Street 1:6100 HARRIS PKWY
Practice Address - Street 2:SUITE 250
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4101
Practice Address - Country:US
Practice Address - Phone:817-433-5179
Practice Address - Fax:817-433-5177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363LG0600X363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty