Healthcare Provider Details

I. General information

NPI: 1073761805
Provider Name (Legal Business Name): JPS PHYSICIAN GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 HEMPHILL ST
FORT WORTH TX
76104-4709
US

IV. Provider business mailing address

19801 ANITA AVE
CASTRO VALLEY CA
94546-4103
US

V. Phone/Fax

Practice location:
  • Phone: 817-852-8440
  • Fax: 817-927-3603
Mailing address:
  • Phone: 650-743-6473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CORBIN WILSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 817-921-3431