Provider Demographics
NPI:1629171186
Name:MEDICAL & HEART CENTER PA
Entity type:Organization
Organization Name:MEDICAL & HEART CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GUDURU
Authorized Official - Middle Name:R
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-341-8646
Mailing Address - Street 1:2614 E BANKHEAD HWY
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-9558
Mailing Address - Country:US
Mailing Address - Phone:817-341-8646
Mailing Address - Fax:817-341-1905
Practice Address - Street 1:2614 E BANKHEAD HWY
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76087-9558
Practice Address - Country:US
Practice Address - Phone:817-341-8646
Practice Address - Fax:817-341-1905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2824207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137429002Medicaid
D97652Medicare UPIN
TX137429002Medicaid