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Organization
FORT WORTH PEDIATRICS, P.A.
Active
Organization
FORT WORTH PEDIATRICS, P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DIANE RICHEY (ADMINISTRATOR)
(817) 336-4040
Entity
Organization
Contact information
Practice address
6401 HARRIS PKWY, SUITE100, FORT WORTH, TX 76132-6101
(817) 346-2525
(817) 294-1692
Mailing address
5708 EDWARDS RANCH ROAD, FORT WORTH, TX 76109
(817) 336-4040
(817) 336-6780
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
—
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00L72L
BCBS
TX
01
—
10001409
AMERIGROUP
TX
05
—
130900702
—
TX
05
—
130900705
—
TX
01
—
8541908
AETNA
TX
Enumeration date
03/30/2007
Last updated
06/14/2011
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