1669476990 NPI number — DR. EVA J BAILEY M.D.

Table of content: LISA A MASSIE MD (NPI 1053366757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669476990 NPI number — DR. EVA J BAILEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAILEY
Provider First Name:
EVA
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1669476990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2457
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:
76113-2457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-332-3664
Provider Business Mailing Address Fax Number:
817-882-9888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
823 PENNSYLVANIA AVE
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:
76104-2224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-332-3664
Provider Business Practice Location Address Fax Number:
817-882-9888
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  H5299 , 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: 079577501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0040CG . This is a "BCBSTX GROUP ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 038391101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82931G . This is a "BCBSTX PROVIDER ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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