Basic Information
| Provider Information | |||||||||
| NPI: | 1174581912 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGHWAY 30 FAMILY MEDICAL CENTER, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9991 MARSH LN | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752201766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143580090 | ||||||||
| FaxNumber: | 2145266851 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 WOODHAVEN BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761122376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174298300 | ||||||||
| FaxNumber: | 8174296167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 04/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | HOFFMAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 81742983000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 153458801 | 05 | TX | MEDICAID | 153458802 | 05 | TX | MEDICAID |