Healthcare Provider Details

I. General information

NPI: 1154028827
Provider Name (Legal Business Name): TELEHEALTH PHYSICIAN NETWORK, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHARLES EWING BLVD STE 160
EWING NJ
08628-3456
US

IV. Provider business mailing address

1315 S ADAMS ST
FORT WORTH TX
76104-4404
US

V. Phone/Fax

Practice location:
  • Phone: 833-484-6359
  • Fax:
Mailing address:
  • Phone: 833-484-6359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: HEATHER GERACIE
Title or Position: AVP CLINICAL EXCELLENCE
Credential: RN
Phone: 817-242-0967