Basic Information
| Provider Information | |||||||||
| NPI: | 1346237955 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BSA PHYSICIANS GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BSA MEDICAL GROUP | ||||||||
| 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: | 3501 S SONCY RD STE 148 | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062126965 | ||||||||
| FaxNumber: | 8062126278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARPOLE | ||||||||
| AuthorizedOfficialFirstName: | EILEEN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8062126965 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 266489 | 01 | TX | GROUP MEDICARE | OTHER | 325874101 | 05 | TX | MEDICAID | 00R06W | 01 | TX | GROUP BCBS | OTHER |