Healthcare Provider Details

I. General information

NPI: 1063417699
Provider Name (Legal Business Name): HEALTHTEXAS PROVIDER NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N VIRGINIA ST
TERRELL TX
75160-2732
US

IV. Provider business mailing address

8080 N CENTRAL EXPY STE 600, LB82
DALLAS TX
75206-1838
US

V. Phone/Fax

Practice location:
  • Phone: 972-551-7500
  • Fax: 972-524-7418
Mailing address:
  • Phone: 972-860-8648
  • Fax: 972-860-8679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00249N
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number00249N
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number00249N
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number00249N
License Number StateTX

VIII. Authorized Official

Name: MRS. ELLEN ELIZABETH FOURTON
Title or Position: DIRECTOR
Credential:
Phone: 972-860-8649