=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659303618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOPEDIC SPECIALTY ASSOCIATES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2006
-----------------------------------------------------
Last Update Date | 09/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 5TH AVE SUITE 500
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-878-5300
-----------------------------------------------------
Fax | 817-878-5300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 5TH AVE SUITE 500
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-878-5300
-----------------------------------------------------
Fax | 817-878-5300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. TRACY HERRERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-878-5444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------