Basic Information
| Provider Information | |||||||||
| NPI: | 1679524011 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EL PASO PHYSICIAN GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9229 LBJ FWY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752433405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727393097 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1626 MEDICAL CENTER DR | ||||||||
| Address2: | 5TH FLOOR, SUITE 503 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799025010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155469200 | ||||||||
| FaxNumber: | 9155469800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | HEIGHTEN | ||||||||
| AuthorizedOfficialFirstName: | CLAY | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9727393001 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 162360502 | 05 | TX | MEDICAID | 162360503 | 05 | TX | MEDICAID | 98535331 | 05 | NM | MEDICAID | 0042KP | 01 | TX | BCBS | OTHER | 162360501 | 05 | TX | MEDICAID |