Provider Demographics
NPI:1992708721
Name:TEXAS CENTER FOR BREAST RECONSTRUCTION
Entity type:Organization
Organization Name:TEXAS CENTER FOR BREAST RECONSTRUCTION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRICE
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCKANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-566-3939
Mailing Address - Street 1:7777 FOREST LN
Mailing Address - Street 2:STE C504
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-6844
Mailing Address - Country:US
Mailing Address - Phone:972-566-3939
Mailing Address - Fax:972-566-3999
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:STE C504
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230
Practice Address - Country:US
Practice Address - Phone:972-566-3939
Practice Address - Fax:972-566-3999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2452208200000X, 2082S0099X
TXM12332082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120616104Medicaid
TX0039BCMedicare ID - Type Unspecified
TX00Y152Medicare PIN