=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407050057
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UROLOGY CONSULTANTS OF FORT WORTH LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2007
-----------------------------------------------------
Last Update Date | 01/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 8TH AVE SUITE 626
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-877-1288
-----------------------------------------------------
Fax | 817-877-5242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 8TH AVE SUITE 626
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-877-1288
-----------------------------------------------------
Fax | 817-877-5242
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LIMITED PARTNER
-----------------------------------------------------
Name | DR. SIDNEY A WORSHAM III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 817-877-1288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | D8491
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------