=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720005523
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTROENTEROLOGY ASSOCIATES OF NORTH TEXAS, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2006
-----------------------------------------------------
Last Update Date | 09/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 W MAGNOLIA AVE STE 100
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-8518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-870-7300
-----------------------------------------------------
Fax | 817-332-8372
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 W MAGNOLIA AVE STE 100 SUITE 100
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-8518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-870-7300
-----------------------------------------------------
Fax | 817-332-8372
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. KIM NELSON BARHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-870-7300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------