MEDICARE: HEALTHTEXAS PROVIDER NETWORK-PHYSIATRIC MEDICINE ASSOCIATES

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	208100000X	Physical Medicine & Rehabilitation Physician	00T89Z	TX

General Provider Information

NPI Number	:	1912902511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHTEXAS PROVIDER NETWORK-PHYSIATRIC MEDICINE ASSOCIATES

Provider Business Mailing Address
First Line	:	8080 N CENTRAL EXPRESSWAY, LB 82
Second Line	:	STE 1650
City	:	DALLAS
State	:	TX
Zip	:	75206
Country	:	US
Telephone Number	:	972-860-8653
Fax Number	:	972-860-8679

Provider Business Practice Location Address
First Line	:	3504 SWISS AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-6224
Country	:	US
Telephone Number	:	214-820-9849
Fax Number	:	214-820-9787

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	:	08/22/2020

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