1063630937 NPI number — HEALTHTEXAS PROVIDER NETWORK

Table of content: (NPI 1063630937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063630937 NPI number — HEALTHTEXAS PROVIDER NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHTEXAS PROVIDER NETWORK
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:
6
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:
1063630937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 844128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-2148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-800-3524
Provider Business Mailing Address Fax Number:
469-800-3564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6257 FM 2642 BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ROYSE CITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75189-3223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-800-3670
Provider Business Practice Location Address Fax Number:
469-800-3680
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
TONIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
469-800-3670

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8G4495 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 091888002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 137940601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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