=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336172105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXAS HEALTH HARRIS METHODIST HOSPITAL FORT WORTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2006
-----------------------------------------------------
Last Update Date | 04/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 PENNSYLVANIA AVE
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-2122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-882-3770
-----------------------------------------------------
Fax | 817-882-3781
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 916063
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76191-6063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-890-6034
-----------------------------------------------------
Fax | 682-236-0103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VP REVENUE CYCLE
-----------------------------------------------------
Name | JEFF MINCHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 682-236-3013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 000235
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 000235
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------