Basic Information
Provider Information | |||||||||
NPI: | 1588662456 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ENGELHART | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4100 INTERNATIONAL PLZ STE 600 | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761094823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8173340530 | ||||||||
FaxNumber: | 8178770350 | ||||||||
Practice Location | |||||||||
Address1: | 181 W MEADOW DR | ||||||||
Address2: |   | ||||||||
City: | VAIL | ||||||||
State: | CO | ||||||||
PostalCode: | 81657 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704762451 | ||||||||
FaxNumber: | 8178770350 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2005 | ||||||||
LastUpdateDate: | 05/23/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 34007108 | OH | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | DR.0050828 | CO | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 114129880 | 01 | MI | MICHIGAN MEDICAID | OTHER | 050072650 | 01 | OH | RAILROAD MEDICARE | OTHER | 2161806 | 05 | OH |   | MEDICAID | 2161806 | 01 | OH | BCMH | OTHER | 050065045 | 01 | OH | RAILROAD MEDICARE | OTHER |