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Organization
HEALTHTEXAS PROVIDER NETWORK
Active
Organization
HEALTHTEXAS PROVIDER NETWORK
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ELLEN ELIZABETH FOURTON (DIRECTOR)
(972) 860-8649
Entity
Organization
Contact information
Practice address
2740 N HWY 360, SUITE 100, GRAND PRAIRIE, TX 75050-6401
(972) 606-8300
(972) 606-4940
Mailing address
8080 N CENTRAL EXPY, LB 82, STE 1650, DALLAS, TX 75206
(972) 860-8648
(972) 860-8679
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
0079BV
TX
207R00000X
Internal Medicine Physician
0079BV
TX
207V00000X
Obstetrics & Gynecology Physician
0079BV
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0079BV
BCBSTX
TX
05
—
0811697-02
—
TX
Enumeration date
06/20/2005
Last updated
01/20/2010
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