Basic Information
| Provider Information | |||||||||
| NPI: | 1538130059 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TXAR 501A CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013676 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 5405 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755031662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032235200 | ||||||||
| FaxNumber: | 9032235213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 10/03/2019 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6105503003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 45D0482326 | TX | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 109469002 | 05 | TX | MEDICAID | 690004016 | 01 | TX | MC RR IL | OTHER | HE23 | 01 | TX | BCBS | OTHER |