Basic Information
Provider Information | |||||||||
NPI: | 1639125131 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | USRC TARRANT LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | USRC TARRANT DIALYSIS FORT WORTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 952074 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753950001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709315400 | ||||||||
FaxNumber: | 8709315418 | ||||||||
Practice Location | |||||||||
Address1: | 501 COLLEGE AVE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761042211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8178775907 | ||||||||
FaxNumber: | 8173326539 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2006 | ||||||||
LastUpdateDate: | 10/28/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEINBERG | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | VP, GENERAL COUNSEL | ||||||||
AuthorizedOfficialTelephone: | 2147362700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | US RENAL CARE, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 008467 | TX | N |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment | 261QE0700X | 110099 | TX | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
ID | Type | State | Issuer | Description | HH6161 | 01 | TX | BLUE CROSS | OTHER | 000876 | 01 | TX | KIDNEY HEALTH CARE | OTHER | 186261702 | 05 | TX |   | MEDICAID | 186261701 | 05 | TX |   | MEDICAID |