MEDICARE: FORT WORTH OCCMED, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083X0100X	Occupational Medicine Physician

General Provider Information

NPI Number	:	1205976040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH OCCMED, LLC

Provider Business Mailing Address
First Line	:	5146 TRAIL LAKE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-2030
Country	:	US
Telephone Number	:	817-921-6284
Fax Number	:	817-922-0160

Provider Business Practice Location Address
First Line	:	4775 SOUTH FWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-3624
Country	:	US
Telephone Number	:	817-921-2500
Fax Number	:	817-921-0625

Authorized Official
Title or Position	:	PARTNER
Name	:	MR. BO BRANNON
Credential	:
Telephone Number	:	817-921-6284

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	08/22/2020

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