Basic Information
| Provider Information | |||||||||
| NPI: | 1144668765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BSA PHYSICIANS GROUP INC | ||||||||
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| OtherOrganizationName: | BAPTIST ST. ANTHONY'S URGENT CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840026 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062126965 | ||||||||
| FaxNumber: | 8062126278 | ||||||||
| Practice Location | |||||||||
| Address1: | 4510 BELL ST | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791095714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062124835 | ||||||||
| FaxNumber: | 8062120900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 11/02/2017 | ||||||||
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| AuthorizedOfficialLastName: | PETROVICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 6152963000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BSA PHYSICIAN HOLDING COMPANY LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.