MEDICARE: PEDIATRIC SURGICAL ASSOCIATES OF FT. WORTH, 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	2086S0120X	Pediatric Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	4641193	OTHER	TX	AETNA

General Provider Information

NPI Number	:	1538140710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC SURGICAL ASSOCIATES OF FT. WORTH, P. A.

Provider Business Mailing Address
First Line	:	901 7TH AVE
Second Line	:	SUITE 210
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2722
Country	:	US
Telephone Number	:	817-336-7881
Fax Number	:	817-336-6821

Provider Business Practice Location Address
First Line	:	901 7TH AVE
Second Line	:	SUITE 210
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2722
Country	:	US
Telephone Number	:	817-336-7881
Fax Number	:	817-336-6821

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DEBRA LOCKETT
Credential	:
Telephone Number	:	817-336-7881

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	06/17/2010

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