MEDICARE: FORT WORTH MED-PEDS ASSOCIATES P.A.

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	261QP2300X	Primary Care Clinic/Center	L2552	TX

General Provider Information

NPI Number	:	1689718975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH MED-PEDS ASSOCIATES P.A.

Provider Business Mailing Address
First Line	:	4545 BELLAIRE DR S
Second Line	:	SUITE 9
City	:	FORT WORTH
State	:	TX
Zip	:	76109-1889
Country	:	US
Telephone Number	:	817-732-6060
Fax Number	:	817-731-2541

Provider Business Practice Location Address
First Line	:	4545 BELLAIRE DR S
Second Line	:	SUITE 9
City	:	FORT WORTH
State	:	TX
Zip	:	76109-1889
Country	:	US
Telephone Number	:	817-732-6060
Fax Number	:	817-731-2541

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STUART CHARLES PICKELL
Credential	:	MD
Telephone Number	:	817-732-6060

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	08/22/2020

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