Healthcare Provider Details

I. General information

NPI: 1376108209
Provider Name (Legal Business Name): EMCC WEATHERFORD ER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 ADAMS DR
WEATHERFORD TX
76086-6266
US

IV. Provider business mailing address

2300 MATLOCK RD STE 35
MANSFIELD TX
76063-5018
US

V. Phone/Fax

Practice location:
  • Phone: 817-594-0911
  • Fax: 817-594-7724
Mailing address:
  • Phone: 469-830-8200
  • Fax: 469-830-8201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE NEWSOM
Title or Position: PRESIDENT
Credential:
Phone: 469-830-8200