MEDICARE: SOUTHWEST COSMETIC DERMATOLOGY ASSOCIATES

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	174400000X	Specialist	E2711	TX

General Provider Information

NPI Number	:	1528271624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST COSMETIC DERMATOLOGY ASSOCIATES

Provider Business Mailing Address
First Line	:	4365 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4917
Country	:	US
Telephone Number	:	817-920-9023
Fax Number	:	817-923-6013

Provider Business Practice Location Address
First Line	:	4365 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4917
Country	:	US
Telephone Number	:	817-920-9023
Fax Number	:	817-923-6013

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JAMES RICHMOND MCCARTY
Credential	:	M.D.
Telephone Number	:	817-920-9023

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	11/10/2011

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