Basic Information
| Provider Information | |||||||||
| NPI: | 1053367763 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | USRC TARRANT LP | ||||||||
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| OtherOrganizationName: | USRC TARRANT DIALYSIS NORTH FORT WORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 952074 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753952074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709315400 | ||||||||
| FaxNumber: | 8709315418 | ||||||||
| Practice Location | |||||||||
| Address1: | 1978 EPHRIHAM AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761646670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176247811 | ||||||||
| FaxNumber: | 8176246112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 10/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | WEINBERG | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 2147362700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | US RENAL CARE INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 008371 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 189731602 | 05 | TX | MEDICAID | HH6454 | 01 | TX | BLUE CROSS | OTHER | 012033 | 01 | TX | KIDNEY HEALTH CARE | OTHER | 189731601 | 05 | TX | MEDICAID | 023058 | 01 | TX | KIDNEY HEALTH CARE (KHC) | OTHER |