MEDICARE: MID-CITIES SURGICAL FIRST ASST. INC

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	246ZS0410X	Surgical Technologist	SA00142	TX

General Provider Information

NPI Number	:	1235335258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-CITIES SURGICAL FIRST ASST. INC

Provider Business Mailing Address
First Line	:	2912 BOURBON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-1624
Country	:	US
Telephone Number	:	817-423-1969
Fax Number	:	817-361-7954

Provider Business Practice Location Address
First Line	:	2912 BOURBON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-1624
Country	:	US
Telephone Number	:	817-423-1969
Fax Number	:	817-361-7954

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. VICTOR LAROSA RUFFIN SR.
Credential	:	LSA CFA
Telephone Number	:	817-423-1969

Provider Enumeration Date	:	06/26/2007
Last Update Date	:	08/22/2020

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