=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295496222
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DFW SURGICAL ASSOCIATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2022
-----------------------------------------------------
Last Update Date | 01/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 N TARRANT PKWY
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76177-8611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-966-6363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 93924
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-0119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REVENUE CYCLE MANAGER
-----------------------------------------------------
Name | EVERLY MILLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-996-6363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------