Basic Information
| Provider Information | |||||||||
| NPI: | 1114186616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY CLINICS OF NORTH TEXAS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 GASTON AVE | ||||||||
| Address2: | SUITE 1205 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146928262 | ||||||||
| FaxNumber: | 2146964190 | ||||||||
| Practice Location | |||||||||
| Address1: | 6124 W PARKER RD | ||||||||
| Address2: | SUITE 434 | ||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750938122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146911902 | ||||||||
| FaxNumber: | 2149871845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | JERRI | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2146911902 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | K3232 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2088P0231X | G9345 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208800000X | M0918 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0036DE | 01 | TX | BCBS GROUP | OTHER | CI6341 | 01 | TX | RRMCR GROUP | OTHER | CI6342 | 01 | TX | RRMCR GROUP | OTHER | 119844202 | 05 | TX | MEDICAID |