1003172636 NPI number — MEDICAL TRANSIT CONNECTION

Table of content: KATHERINE ANNE WIDERBORG MD (NPI 1588757579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003172636 NPI number — MEDICAL TRANSIT CONNECTION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL TRANSIT CONNECTION
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:
Provider Other Organization Name Type Code:
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:
1003172636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1609 CHEYENNE TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-7958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-946-5107
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1609 CHEYENNE TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76063-7958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-946-5107
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JUSTICE
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
AGENT
Authorized Official Telephone Number:
817-946-5107

Provider Taxonomy Codes

  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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