=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033589742
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELECT AMBULATORY SURGERY CENTER OF FT WORTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2015
-----------------------------------------------------
Last Update Date | 01/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 COOPER ST
-----------------------------------------------------
City | FT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-334-0990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 674394
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75267-4394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-479-1115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF NETWORK DEVELOPMENT
-----------------------------------------------------
Name | KRISTY MCGILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-215-7410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------