1982784195 NPI number — TEXAS HEART CLINIC PA

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 1982784195 NPI number — TEXAS HEART CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS HEART CLINIC PA
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:
1982784195
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12229
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:
76110-8229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1307 8TH AVE
Provider Second Line Business Practice Location Address:
SUITE 501
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-922-9050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIDERHORN
Authorized Official First Name:
JOSEF
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
817-922-9050

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: J2843 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: J2843 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: J2843 , 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: 2500101 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2837065012 . This is a "CIGNA HMO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 168218901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4236959 . This is a "AETNA PPO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2171076 . This is a "AETNA HMO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 60055861 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0071DU . This is a "BCBS OF TEXAS GROUP #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2837065007 . This is a "CIGNA PPO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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