MEDICARE: BEASLEY MEDICAL CLINIC

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	207Q00000X	Family Medicine Physician	H7882	TX

General Provider Information

NPI Number	:	1922263672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEASLEY MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	3256 LACKLAND RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5307
Country	:	US
Telephone Number	:	817-625-9292
Fax Number	:

Provider Business Practice Location Address
First Line	:	3256 LACKLAND RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5307
Country	:	US
Telephone Number	:	817-625-9292
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	STEPHANIE BARKOCI
Credential	:
Telephone Number	:	817-625-9292

Provider Enumeration Date	:	07/22/2008
Last Update Date	:	07/22/2008

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