=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609552249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRATEGIC MEDICAL GROUP TX PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2023
-----------------------------------------------------
Last Update Date | 06/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 8TH AVE STE 626
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-2605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-243-7995
-----------------------------------------------------
Fax | 844-573-3209
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7101 BRYANT IRVIN RD # 33292
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76132-4135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-433-5155
-----------------------------------------------------
Fax | 844-573-3209
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE OWNER
-----------------------------------------------------
Name | OMAR F SELOD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 817-243-7995
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------