1407821366 NPI number — GERALD GENE PAYNE JR. MD

Table of content: GERALD GENE PAYNE JR. MD (NPI 1407821366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407821366 NPI number — GERALD GENE PAYNE JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAYNE
Provider First Name:
GERALD
Provider Middle Name:
GENE
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1407821366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100186
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:
76185-0186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-731-7771
Provider Business Mailing Address Fax Number:
817-731-7774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 W COLLEGE ST
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
GRAPEVINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76051-3580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-481-0111
Provider Business Practice Location Address Fax Number:
817-481-0112
Provider Enumeration Date:
02/22/2006

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: 207VM0101X , with the licence number:  G3678 , 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: 135806115 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 74999 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 135806110 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4292523 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 135806109 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8H3361 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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