Basic Information
| Provider Information | |||||||||
| NPI: | 1568486264 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OBSTETRIX MEDICAL GROUP OF TEXAS BILLING, INC. | ||||||||
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| OtherOrganizationName: | OBSTETRIX MEDICAL GROUP OF TEXAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 CONCORD TER | ||||||||
| Address2: | |||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543840175 | ||||||||
| FaxNumber: | 9548511948 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 E PRESIDENT GEORGE BUSH HWY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750823542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724375099 | ||||||||
| FaxNumber: | 9727641661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | DWYER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9543840175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEDIATRIX MEDICAL SERVICES INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00291Z | 01 | TX | MEDICARE | OTHER | 7029142 | 01 | TX | AETNA | OTHER | 79601B001 | 01 | TX | TRICARE | OTHER | 76015A001 | 01 | TX | TRICARE | OTHER | 81106343 | 05 | TX | MEDICAID | 00022K | 01 | TX | MEDICARE | OTHER | 76104A001 | 01 | TX | TRICARE | OTHER | 00022K | 01 | TX | BCBS | OTHER | 00454R | 01 | TX | MEDICARE | OTHER | 31438750 | 05 | TX | MEDICAID | 079584101 | 05 | TX | MEDICAID | 100726580A | 05 | TX | MEDICAID | 100726620A | 05 | TX | MEDICAID | 177389701 | 05 | TX | MEDICAID |