Provider Demographics
NPI:1033399803
Name:PHYSICIANS SURGICAL CENTER OF FT. WORTH, L.L.P
Entity Type:Organization
Organization Name:PHYSICIANS SURGICAL CENTER OF FT. WORTH, L.L.P
Other - Org Name:PHYSICIANS SURGICAL CENTER OF FORT WORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN MSN CASC
Authorized Official - Phone:817-570-0203
Mailing Address - Street 1:975 HASKELL ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2653
Mailing Address - Country:US
Mailing Address - Phone:817-570-0200
Mailing Address - Fax:817-570-0280
Practice Address - Street 1:975 HASKELL ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2653
Practice Address - Country:US
Practice Address - Phone:817-570-0200
Practice Address - Fax:817-570-0280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008484261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical