MEDICARE: M NAZARIAN MD ASSOC

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	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	D9248	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4584370009	OTHER		CIGNA
2	0613110	OTHER		AETNA

General Provider Information

NPI Number	:	1497809925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M NAZARIAN MD ASSOC

Provider Business Mailing Address
First Line	:	757 8TH AVE
Second Line	:	SUITE A
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2522
Country	:	US
Telephone Number	:	817-336-4454
Fax Number	:	817-336-4440

Provider Business Practice Location Address
First Line	:	757 8TH AVE
Second Line	:	M NAZARIAN MD ASSOC
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2522
Country	:	US
Telephone Number	:	817-336-4454
Fax Number	:	817-336-4440

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MANUCHER NAZARIAN
Credential	:	MD
Telephone Number	:	817-336-4454

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	07/27/2007

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