1558362756 NPI number — DR. RALPH JOHN FITZGERALD M.D.

Table of content: DR. RALPH JOHN FITZGERALD M.D. (NPI 1558362756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558362756 NPI number — DR. RALPH JOHN FITZGERALD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
RALPH
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1558362756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2429
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COPPELL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75019-8429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-420-1475
Provider Business Mailing Address Fax Number:
469-671-5437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2560 CENTRAL PARK AVE
Provider Second Line Business Practice Location Address:
SUITE 195
Provider Business Practice Location Address City Name:
FLOWER MOUND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75028-1554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-420-1475
Provider Business Practice Location Address Fax Number:
469-671-5437
Provider Enumeration Date:
08/10/2005

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: 208000000X , with the licence number:  H0841 , 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: 039538602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81M644 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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