Basic Information
| Provider Information | |||||||||
| NPI: | 1346585809 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BSA HARRINGTON PHYSICIANS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840048 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062125079 | ||||||||
| FaxNumber: | 8062126278 | ||||||||
| Practice Location | |||||||||
| Address1: | 1751 WALLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062124673 | ||||||||
| FaxNumber: | 8062120057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2012 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | PETROVICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 6152963000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BSA PHYSICIAN HOLDING COMPANY LLC | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 136269114 | 05 | TX | MEDICAID | 330222YNR6 | 01 | TX | MEDICARE | OTHER |