Basic Information
| Provider Information | |||||||||
| NPI: | 1851394753 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDFUND LLC | ||||||||
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| OtherOrganizationName: | HORIZON FORT WORTH LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342365945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419253490 | ||||||||
| FaxNumber: | 9419534452 | ||||||||
| Practice Location | |||||||||
| Address1: | 7440 OAKMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761323904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172942400 | ||||||||
| FaxNumber: | 8172942402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KERN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9419253490 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | 0340DC | 01 | TX | BCBS PROV # | OTHER | 7195603 | 01 | AETNA/MEDSOLUTIONS | OTHER | 242885 | 01 | AMERIGROUP | OTHER |