Basic Information
| Provider Information | |||||||||
| NPI: | 1780971549 | ||||||||
| 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: | 1600 W COLLEGE ST | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760513580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148266021 | ||||||||
| FaxNumber: | 2149871845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2011 | ||||||||
| LastUpdateDate: | 01/31/2017 | ||||||||
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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 | 174400000X | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 119844209 | 05 | TX | MEDICAID |