MEDICARE: FORT WORTH FAMILY PRACTICE 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	207Q00000X	Family Medicine Physician		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00436N	OTHER	TX	BCBS
2	8440J0	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1356520134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH FAMILY PRACTICE ASSOCIATED

Provider Business Mailing Address
First Line	:	8030 CAMP BOWIE W
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-6313
Country	:	US
Telephone Number	:	817-244-4620
Fax Number	:	817-560-7159

Provider Business Practice Location Address
First Line	:	8030 CAMP BOWIE W
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-6313
Country	:	US
Telephone Number	:	817-244-4620
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	SANDRA ELLIS
Credential	:
Telephone Number	:	817-244-4620

Provider Enumeration Date	:	10/30/2007
Last Update Date	:	11/11/2009

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