Basic Information
| Provider Information | |||||||||
| NPI: | 1134223357 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH AND HUMAN SERVICES COMMISSION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NORTH TEXAS STATE HOSPITAL (WF CAMPUS) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4110 GUADALUPE ST | ||||||||
| Address2: | HOSPITAL REVENUE MGMT-MC2028 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787514223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122065011 | ||||||||
| FaxNumber: | 5122065302 | ||||||||
| Practice Location | |||||||||
| Address1: | 6515 KEMP BLVD. | ||||||||
| Address2: | |||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763085419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406895201 | ||||||||
| FaxNumber: | 9406895784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM SUPERVISOR VI | ||||||||
| AuthorizedOfficialTelephone: | 5124383124 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | TX | N | Suppliers | Pharmacy | Institutional Pharmacy | 3336L0003X | TX | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | HH3005 | 01 | TX | BCBS DRUG/ALCOHOL | OTHER | 0211955-01 | 05 | TX | MEDICAID | 1372468-02 | 05 | TX | MEDICAID | 1372468-04 | 05 | TX | MEDICAID | HH4614 | 01 | TX | BCBS PSYCHIATRIC | OTHER | 0638249-01 | 05 | TX | MEDICAID | 0827958-01 | 05 | TX | MEDICAID | 1372468-03 | 05 | TX | MEDICAID | 4538344 | 01 | TX | PHARMACY NCPDP NUMBER | OTHER |