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General NPI Number Information
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NPI Number | 1679561641
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Entity Type | Organization
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Legal Business Name | FORTH WORTH SURGICAL ASSOCIATES PA
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Dates
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Enumeration Date | 10/12/2005
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Last Update Date | 11/28/2007
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Provider Practice Location Address
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Address Line | 6100 HARRIS PKWY #390
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City | FORT WORTH
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State | TX
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Zip | 76132-4128
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Country | US
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Telephone | 817-370-9011
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Fax | 817-346-0380
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Provider Business Mailing Address
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Address Line | 6100 HARRIS PKWY #390
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City | FORT WORTH
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State | TX
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Zip | 76132-4128
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Country | US
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Telephone | 817-370-9011
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Fax | 817-346-0380
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Authorized Official
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Title or Position | OWNER
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Name | WILLIAM ROBERT PETTEY
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Credential | MD
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Telephone | 817-370-9011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | G8340
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License Number State | TX
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