MEDICARE: SALLY A HALLGREN, D.O., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0000X	Pain Medicine Physician	E9484	TX

General Provider Information

NPI Number	:	1336425289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALLY A HALLGREN, D.O., P.A.

Provider Business Mailing Address
First Line	:	311 UNIVERSITY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-1924
Country	:	US
Telephone Number	:	817-877-4787
Fax Number	:	817-877-1654

Provider Business Practice Location Address
First Line	:	311 UNIVERSITY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-1924
Country	:	US
Telephone Number	:	817-877-4787
Fax Number	:	817-877-1654

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	STEPHANIE JANE WILLIAMS
Credential	:
Telephone Number	:	817-877-4787

Provider Enumeration Date	:	10/24/2011
Last Update Date	:	11/21/2011

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