1033311857 NPI number — ROCKWOOD MEDICAL CLINIC, P.A.

Table of content: (NPI 1033311857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033311857 NPI number — ROCKWOOD MEDICAL CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROCKWOOD MEDICAL CLINIC, P.A.
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:
1033311857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4705
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:
76164-0705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-625-7733
Provider Business Mailing Address Fax Number:
817-740-1602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1217 GRAND 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:
76106-9041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-625-7733
Provider Business Practice Location Address Fax Number:
817-740-1602
Provider Enumeration Date:
06/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GARZA
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
817-625-7733

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  H0411 , 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: 8J1230 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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