MEDICARE: DFW SURGICAL ASSOCIATED

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	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1295496222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DFW SURGICAL ASSOCIATED

Provider Business Mailing Address
First Line	:	PO BOX 93924
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-0119
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3200 N TARRANT PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-8611
Country	:	US
Telephone Number	:	210-966-6363
Fax Number	:

Authorized Official
Title or Position	:	REVENUE CYCLE MANAGER
Name	:	EVERLY MILLER
Credential	:
Telephone Number	:	210-996-6363

Provider Enumeration Date	:	01/03/2022
Last Update Date	:	01/03/2022

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Directions to “DFW SURGICAL ASSOCIATED ” Practice Location

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