Basic Information
| Provider Information | |||||||||
| NPI: | 1336343235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROURKE | ||||||||
| FirstName: | LOREN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722340813 | ||||||||
| Practice Location | |||||||||
| Address1: | 9180 PINECROFT DR STE 600 | ||||||||
| Address2: | |||||||||
| City: | SHENANDOAH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812960365 | ||||||||
| FaxNumber: | 2812988907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 11/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | MD19902 | ME | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 2086X0206X | N4049 | TX | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 2086X0206X | 11465 | MT | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 8FK213 | 01 | TX | BCBS | OTHER | 8GD975 | 01 | TX | BCBS | OTHER | 205095705 | 05 | TX | MEDICAID | 205095704 | 05 | TX | MEDICAID | N4049 | 01 | TX | STATE LICENSE | OTHER | 205095701 | 05 | TX | MEDICAID | 205095702 | 05 | TX | MEDICAID |