Healthcare Provider Details

I. General information

NPI: 1104382340
Provider Name (Legal Business Name): EMCC AZLE FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 NORTHWEST PKWY STE C
AZLE TX
76020-2930
US

IV. Provider business mailing address

2300 MATLOCK RD STE 35
MANSFIELD TX
76063-5018
US

V. Phone/Fax

Practice location:
  • Phone: 817-270-0788
  • Fax:
Mailing address:
  • Phone: 469-830-8200
  • Fax: 469-830-8201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE NEWSOM
Title or Position: VP OF OPERATIONS
Credential:
Phone: 817-271-2583