Provider Demographics
NPI:1871598458
Name:HEALTHTEXAS PROVIDER NETWORK - WAXAHACHIE SURGICAL SPECIALIST, LLP
Entity type:Organization
Organization Name:HEALTHTEXAS PROVIDER NETWORK - WAXAHACHIE SURGICAL SPECIALIST, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:FOURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-860-8649
Mailing Address - Street 1:8060 N CENTRAL EXPY
Mailing Address - Street 2:STE 1650
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-1801
Mailing Address - Country:US
Mailing Address - Phone:972-860-8653
Mailing Address - Fax:972-860-8679
Practice Address - Street 1:1505 W JEFFERSON ST
Practice Address - Street 2:STE 165
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2200
Practice Address - Country:US
Practice Address - Phone:972-923-1457
Practice Address - Fax:972-923-1304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2008-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00863W208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00863WMedicare PIN