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General NPI Number Information
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NPI Number | 1083045041
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Entity Type | Organization
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Legal Business Name | BROOKS SURGERY CLINIC, PLLC
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Dates
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Enumeration Date | 12/02/2013
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Last Update Date | 01/15/2014
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Provider Practice Location Address
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Address Line | 2260 COLLEGE AVE
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City | FORT WORTH
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State | TX
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Zip | 76110-1952
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Country | US
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Telephone | 817-870-0172
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Fax | 817-870-0158
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Provider Business Mailing Address
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Address Line | PO BOX 12630
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City | FORT WORTH
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State | TX
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Zip | 76110-8630
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Country | US
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Telephone | 817-870-0172
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Fax | 817-870-0158
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Authorized Official
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Title or Position | OWNER
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Name | DR. MICHAEL EDWIN BROOKS
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Credential | M.D.
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Telephone | 817-870-0172
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | H7704
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License Number State | TX
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