1023017068 NPI number — ORTHOPEDIC SURGERY PAVILION, LP

Table of content: (NPI 1023017068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023017068 NPI number — ORTHOPEDIC SURGERY PAVILION, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPEDIC SURGERY PAVILION, LP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ORTHOPEDIC SURGERY PAVILION
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023017068
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 961094
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76161-0094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-877-1291
Provider Business Mailing Address Fax Number:
817-877-1292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 COOPER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-2529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-877-1291
Provider Business Practice Location Address Fax Number:
817-877-1292
Provider Enumeration Date:
07/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MILNE
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
817-493-2356

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  007075 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RRMCHCX12 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 60054 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75261 . This is a "PHCS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: HH1507 . This is a "BLUE CROSS BUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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