MEDICARE: NORTSIDE MEDICAL CLINIC, P.A.

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1285755504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTSIDE MEDICAL CLINIC, P.A.

Provider Business Mailing Address
First Line	:	1600 25TH STREET
Second Line	:	SUITE B
City	:	FORT WORTH
State	:	TX
Zip	:	76106
Country	:	US
Telephone Number	:	817-626-3434
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 25TH STREET
Second Line	:	SUITE B
City	:	FORT WORTH
State	:	TX
Zip	:	76106
Country	:	US
Telephone Number	:	817-626-3434
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRUCE E. WARDLAY
Credential	:	D.O.
Telephone Number	:	817-626-3434

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	08/22/2020

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