1821058132 NPI number — MRS. SUSAN KEITH LINDER MD

Table of content: (NPI 1255851580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821058132 NPI number — MRS. SUSAN KEITH LINDER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LINDER
Provider First Name:
SUSAN
Provider Middle Name:
KEITH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1821058132
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 961013
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:
76161-0013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-926-7671
Provider Business Mailing Address Fax Number:
817-926-7772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 S HULEN ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76109-1504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-926-7671
Provider Business Practice Location Address Fax Number:
817-926-7772
Provider Enumeration Date:
03/23/2006

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: 208100000X , with the licence number:  H8972 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2081P2900X , with the licence number: H8972 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: BCBS . This is a "00L11W" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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