MEDICARE: FORT WORTH CLINIC SPECIALTY CARE PLLC

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	F2508	TX

General Provider Information

NPI Number	:	1760635346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH CLINIC SPECIALTY CARE PLLC

Provider Business Mailing Address
First Line	:	909 NINTH AVENUE
Second Line	:	SUITE 300
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3917
Country	:	US
Telephone Number	:	817-336-7191
Fax Number	:	817-332-3172

Provider Business Practice Location Address
First Line	:	9003 AIRPORT FREEWAY
Second Line	:	SUITE 300
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-9628
Country	:	US
Telephone Number	:	817-514-5200
Fax Number	:	817-514-5210

Authorized Official
Title or Position	:	SOLE MBR
Name	:	DR. GEORGE JAY ZIMMERMAN
Credential	:	M.D.
Telephone Number	:	817-336-7191

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	02/23/2009

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