1487600904 NPI number — USRC TARRANT L P

Table of content: IRAKLI SOULAKVELIDZE MD (NPI 1588638670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487600904 NPI number — USRC TARRANT L P

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
USRC TARRANT L P
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:
1487600904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 952074
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:
75395-2074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-931-5400
Provider Business Mailing Address Fax Number:
870-931-5418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 E BERRY ST STE 8
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:
76105-5052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-531-0326
Provider Business Practice Location Address Fax Number:
817-531-0332
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEINBERG
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
214-736-2700

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  008457 , 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: 186431606 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: HH6397 . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 023049 . This is a "KIDNEY HEALTH CARE (KHC)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 186431607 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003891 . This is a "KIDNEY HEALTH CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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