Basic Information
| Provider Information | |||||||||
| NPI: | 1194765586 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LONESTAR PROVIDER NETWORK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DALLAS MEDICAL SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 404390 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303844390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | 6153737651 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN | ||||||||
| Address2: | SUITE C-300 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725666000 | ||||||||
| FaxNumber: | 9725666237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 09/28/2007 | ||||||||
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| AuthorizedOfficialLastName: | HADDOCK | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9725666000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0092LT | 01 | TX | BCBS OF TX (AUSTIN) | OTHER |