1871843284 NPI number — PEDIATRIC URGENT CARE CENTER OF NORTH TEXAS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871843284 NPI number — PEDIATRIC URGENT CARE CENTER OF NORTH TEXAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC URGENT CARE CENTER OF NORTH TEXAS
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:
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:
1871843284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 TEXAS SAGE TRL
Provider Second Line Business Mailing Address:
148
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76177-8603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-271-4309
Provider Business Mailing Address Fax Number:
817-750-7336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 TEXAS SAGE TRL
Provider Second Line Business Practice Location Address:
148
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76177-8603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-271-4309
Provider Business Practice Location Address Fax Number:
817-750-7336
Provider Enumeration Date:
09/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
COWAN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-271-4309

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  H9459 , 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)





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