MEDICARE: HEALTHTEXAS PROVIDER NETWORK

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	207V00000X	Obstetrics & Gynecology Physician	0079BV	TX
2	207R00000X	Internal Medicine Physician	0079BV	TX
3	207Q00000X	Family Medicine Physician	0079BV	TX

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	0079BV	OTHER	TX	BCBSTX

General Provider Information

NPI Number	:	1528063146
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHTEXAS PROVIDER NETWORK

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	:	2740 N HWY 360
Second Line	:	SUITE 100
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75050-6401
Country	:	US
Telephone Number	:	972-606-8300
Fax Number	:	972-606-4940

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

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	01/20/2010

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Directions to “HEALTHTEXAS PROVIDER NETWORK ” Practice Location

Language	Start Address	Practice Location

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