Basic Information
| Provider Information | |||||||||
| NPI: | 1194776872 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METROPLEX MEDICAL REHABILITATION & SPORTS MEDICINE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 678596 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752678595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174239054 | ||||||||
| FaxNumber: | 8174239719 | ||||||||
| Practice Location | |||||||||
| Address1: | 6116 OAKBEND TRL | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761323925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174239054 | ||||||||
| FaxNumber: | 8174239719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 09/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8172849850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | K5755 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0033DV | 01 | TX | BCBS | OTHER | 178029801 | 05 | TX | MEDICAID | 0030PX | 01 | BCBS | OTHER | 0033DV | 01 | TX | BCBS GROUP NUMBER | OTHER |