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General NPI Number Information
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NPI Number | 1972623031
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Entity Type | Organization
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Legal Business Name | FORT WORTH PEDIATRICS, P.A.
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Dates
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Enumeration Date | 03/30/2007
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Last Update Date | 06/14/2011
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Provider Practice Location Address
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Address Line | 1108 S HENDERSON ST
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City | FORT WORTH
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State | TX
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Zip | 76104-4430
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Country | US
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Telephone | 817-335-3255
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Fax | 817-336-6780
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Provider Business Mailing Address
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Address Line | 5708 EDWARDS RANCH ROAD
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City | FORT WORTH
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State | TX
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Zip | 76109
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Country | US
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Telephone | 817-336-4040
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Fax | 817-336-6780
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | DIANE RICHEY
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Credential |
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Telephone | 817-336-4040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number |
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License Number State | TX
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