Basic Information
Provider Information | |||||||||
NPI: | 1417054024 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER AT FORT WORTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 99335 | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761990335 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8177352000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 855 MONTGOMERY ST | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 76107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8177352000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2006 | ||||||||
LastUpdateDate: | 06/06/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HENDERSON | ||||||||
AuthorizedOfficialFirstName: | LESLIE | ||||||||
AuthorizedOfficialMiddleName: | MCGEE | ||||||||
AuthorizedOfficialTitleorPosition: | REVENUE CYCLE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8177352008 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER AT FORT WORTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy | 363A00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 023088001 | 05 | TX |   | MEDICAID | 138980120 | 05 | TX |   | MEDICAID | 138980107 | 05 | TX |   | MEDICAID | 023088002 | 01 | TX | MEDICAID CSHCN | OTHER |