=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003208091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICTORY MEDICAL CENTER FORT WORTH, LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2015
-----------------------------------------------------
Last Update Date | 02/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 SOUTH MAIN
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-863-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2201 TIMBERLOCH PL SUITE 200
-----------------------------------------------------
City | THE WOODLANDS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77380-1141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF COMPLIANCE OFFICER
-----------------------------------------------------
Name | BELINDA SIMPSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-863-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------