MEDICARE: ADVANCED MEDICAL OF NORTH TEXAS 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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1871185306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED MEDICAL OF NORTH TEXAS PLLC

Provider Business Mailing Address
First Line	:	5500 N TARRANT PKWY STE 108
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5392
Country	:	US
Telephone Number	:	817-605-9500
Fax Number	:	817-605-9503

Provider Business Practice Location Address
First Line	:	5500 N TARRANT PKWY STE 108
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5392
Country	:	US
Telephone Number	:	817-605-9500
Fax Number	:	817-605-9503

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SPENCER SHANLEY
Credential	:
Telephone Number	:	817-605-9500

Provider Enumeration Date	:	02/05/2021
Last Update Date	:	02/05/2021

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