MEDICARE: FORT WORTH PLASTIC SURGERY CENTER

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	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1639397326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH PLASTIC SURGERY CENTER

Provider Business Mailing Address
First Line	:	800 12TH AVE STE 100
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2519
Country	:	US
Telephone Number	:	817-810-0600
Fax Number	:	817-348-8951

Provider Business Practice Location Address
First Line	:	800 12TH AVE STE 100
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2519
Country	:	US
Telephone Number	:	817-810-0600
Fax Number	:	817-348-8951

Authorized Official
Title or Position	:	BOOKKEEPER
Name	:	SHERI HUMPHREYS
Credential	:
Telephone Number	:	817-810-0600

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	08/22/2020

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Directions to “FORT WORTH PLASTIC SURGERY CENTER ” Practice Location

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