Basic Information
| Provider Information | |||||||||
| NPI: | 1104875624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REPUBLIC EMERGENCY SERVICES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24921 | ||||||||
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| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761241921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174514208 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 N HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SHERMAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750927354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038704609 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 07/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | STACKS | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9038704609 | ||||||||
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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 | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00U33U | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 170359701 | 05 | TX | MEDICAID |