Basic Information
| Provider Information | |||||||||
| NPI: | 1013559707 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK ACRE EMERGENCY PHYSICIANS MEDICAL GROUP PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8292 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761240292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174514208 | ||||||||
| FaxNumber: | 8175633699 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | LAKEWAY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787385621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174514208 | ||||||||
| FaxNumber: | 8175633699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2019 | ||||||||
| LastUpdateDate: | 10/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | DAWSON | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8174514208 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.