Basic Information
| Provider Information | |||||||||
| NPI: | 1790778256 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY ASSOCIATES OF NORTH TEXAS LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 120549 | ||||||||
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| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760120549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173034521 | ||||||||
| FaxNumber: | 8174592856 | ||||||||
| Practice Location | |||||||||
| Address1: | 811 W INTERSTATE 20 | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177840818 | ||||||||
| FaxNumber: | 8172761861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CENTRAL BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8173034521 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 109535803 | 05 | TX | MEDICAID |