MEDICARE: HEALTHTEXAS PROVIDER NETWORK-ORTHOPEDIC SERVICES, 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	207X00000X	Orthopaedic Surgery Physician	00303W	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0032KV	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1144226218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHTEXAS PROVIDER NETWORK-ORTHOPEDIC SERVICES, LLP

Provider Business Mailing Address
First Line	:	8080 N CENTRAL EXPY, LB 82
Second Line	:	STE 1650
City	:	DALLAS
State	:	TX
Zip	:	75206
Country	:	US
Telephone Number	:	972-860-8648
Fax Number	:	972-860-8679

Provider Business Practice Location Address
First Line	:	3600 GASTON AVE
Second Line	:	STE 1101
City	:	DALLAS
State	:	TX
Zip	:	75246-1811
Country	:	US
Telephone Number	:	214-820-8350
Fax Number	:	214-820-8355

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

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	03/12/2008

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