MEDICARE: HEALTH TEXAS PROVIDER NETWORK-FAMILY PRACTICE OF NORTH TEXAS LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	00997Y	TX

General Provider Information

NPI Number	:	1114919172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTH TEXAS PROVIDER NETWORK-FAMILY PRACTICE OF NORTH TEXAS LLP

Provider Business Mailing Address
First Line	:	8080 N CENTRAL EXPY
Second Line	:	SUITE 1650
City	:	DALLAS
State	:	TX
Zip	:	75206-1838
Country	:	US
Telephone Number	:	972-860-8653
Fax Number	:	972-860-8679

Provider Business Practice Location Address
First Line	:	1001 12TH AVE
Second Line	:	SUITE 130
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3926
Country	:	US
Telephone Number	:	817-921-6166
Fax Number	:	817-921-9594

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. ELLEN ELIZABETH FOURTON
Credential	:
Telephone Number	:	972-860-8649

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	02/19/2008

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