Basic Information
| Provider Information | |||||||||
| NPI: | 1659473056 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER AT FORT WORTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99335 | ||||||||
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| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177352000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1307 8TH AVE STE 403 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6822071375 | ||||||||
| FaxNumber: | 6822071377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8177352008 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER AT FORT WORTH | ||||||||
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| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 367A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 138980118 | 05 | TX | MEDICAID |