1669423406 NPI number — NEUROLOGY ASSOCIATES OF FORT WORTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669423406 NPI number — NEUROLOGY ASSOCIATES OF FORT WORTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROLOGY ASSOCIATES OF FORT WORTH
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:
1669423406
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 961013
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:
76161-0013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-332-2876
Provider Business Mailing Address Fax Number:
817-877-3672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-2158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-332-2876
Provider Business Practice Location Address Fax Number:
817-877-3672
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLAIR
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-332-2876

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00BR07 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: C14514 . This is a "MEDICARE RR GROUP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 095026302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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