MEDICARE: HIGHWAY 30 FAMILY MEDICAL CENTER, PA

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174581912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGHWAY 30 FAMILY MEDICAL CENTER, PA

Provider Business Mailing Address
First Line	:	9991 MARSH LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75220-1766
Country	:	US
Telephone Number	:	214-358-0090
Fax Number	:	214-526-6851

Provider Business Practice Location Address
First Line	:	1200 WOODHAVEN BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-2376
Country	:	US
Telephone Number	:	817-429-8300
Fax Number	:	817-429-6167

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. MICHAEL D HOFFMAN
Credential	:	DO
Telephone Number	:	81742983000

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	04/09/2012

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