MEDICARE: NEUROSURGICAL AND SPINE CONSULTANTS, PA

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	174400000X	Specialist	J0729	TX

General Provider Information

NPI Number	:	1558754705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEUROSURGICAL AND SPINE CONSULTANTS, PA

Provider Business Mailing Address
First Line	:	1001 12TH AVE STE 171
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3926
Country	:	US
Telephone Number	:	817-576-6500
Fax Number	:	682-703-2064

Provider Business Practice Location Address
First Line	:	1001 12TH AVE
Second Line	:	STE 170
City	:	FT WORTH
State	:	TX
Zip	:	76104-3926
Country	:	US
Telephone Number	:	214-373-3183
Fax Number	:	214-361-5601

Authorized Official
Title or Position	:	OWNER/PHYSCIAN
Name	:	DIANA E WILSON
Credential	:	M.D.
Telephone Number	:	817-576-6500

Provider Enumeration Date	:	03/12/2015
Last Update Date	:	01/02/2019

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