Basic Information
| Provider Information | |||||||||
| NPI: | 1235184094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | GAIL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 CHERRY ST | ||||||||
| Address2: | ST 400, LB#49 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761026803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828856800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 08/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 0101239704 | VA | N | Other Service Providers | Legal Medicine | 208000000X | N1620 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 205616002 | 01 | TX | CSHCN | OTHER | 010260221 | 05 | VA | MEDICAID | 205616001 | 05 | TX | MEDICAID | 8CB421 | 01 | TX | BCBS | OTHER |