Provider Demographics
NPI:1083045041
Name:BROOKS SURGERY CLINIC, PLLC
Entity Type:Organization
Organization Name:BROOKS SURGERY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-870-0172
Mailing Address - Street 1:PO BOX 12630
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-8630
Mailing Address - Country:US
Mailing Address - Phone:817-870-0172
Mailing Address - Fax:817-870-0158
Practice Address - Street 1:2260 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1952
Practice Address - Country:US
Practice Address - Phone:817-870-0172
Practice Address - Fax:817-870-0158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7704208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty