Basic Information
| Provider Information | |||||||||
| NPI: | 1437668951 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONE STAR PROGRESSIVE MEDICINE OF BURLESON PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1320 NW JOHN JONES DR | ||||||||
| Address2: | |||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760288040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172977100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1320 NW JOHN JONES DR | ||||||||
| Address2: | |||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760288040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172977100 | ||||||||
| FaxNumber: | 8172977193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PETTKE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | BRANDON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8172977100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.