MEDICARE: DR. JOSEF WIDERHORN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	J2843	TX
2	207RC0000X	Cardiovascular Disease Physician	J2843	TX
3	207RC0001X	Clinical Cardiac Electrophysiology Physician	J2843	TX
4	207RI0011X	Interventional Cardiology Physician	J2843	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
8	85K247	OTHER	TX	MEDICARE PIN (HARRIS HOSP
9	60055861	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	85K247	OTHER	TX	BLUE CROSS (HARRIS HOSP)
2	2837065-007	OTHER	TX	CIGNA PPO
3	2837065-012	OTHER	TX	CIGNA HMO
4	E51105	OTHER	TX	TRICARE (HARRIS HOSP)
5	2500101	OTHER	TX	UNITED HEALTHCARE
6	4236959	OTHER	TX	AETNA PPO
7	80420Y	OTHER	TX	BLUE CROSS BLUE SHIELD
10	2171076	OTHER	TX	ATNA HMO

General Provider Information

NPI Number	:	1053502583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEF WIDERHORN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 12229
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-8229
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1307 8TH AVE STE 501
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4143
Country	:	US
Telephone Number	:	817-922-9050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	04/02/2008

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