Basic Information
| Provider Information | |||||||||
| NPI: | 1346306701 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS HEALTH CARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 961205 | ||||||||
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| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8173783699 | ||||||||
| Practice Location | |||||||||
| Address1: | 508 S ADAMS ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173325099 | ||||||||
| FaxNumber: | 8173329093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | TATUM | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8177408400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 155109501 | 05 | TX | MEDICAID | 45D0969321 | 01 | TX | CLIA | OTHER |