1033560222 NPI number — FORTWORTH RENAL GROUP PA

Table of content: (NPI 1033560222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033560222 NPI number — FORTWORTH RENAL GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORTWORTH RENAL GROUP PA
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:
KIDNEY AND HYPERTENSION SPECIALISTS OF FORT WORTH
Provider Other Organization Name Type Code:
4
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:
1033560222
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1902 WINDSOR PL STE 102
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:
76110-1866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-207-1700
Provider Business Mailing Address Fax Number:
682-250-5246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1902 WINDSOR PL STE 102
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:
76110-1866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
682-207-1700
Provider Business Practice Location Address Fax Number:
682-250-5246
Provider Enumeration Date:
06/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
AFOLABI
Authorized Official First Name:
OLADAPO
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
817-360-6081

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1033560222 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com