Provider Demographics
NPI:1366442931
Name:THE FORT WORTH CLINIC PA
Entity Type:Organization
Organization Name:THE FORT WORTH CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGHFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-336-7191
Mailing Address - Street 1:909 9TH AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3903
Mailing Address - Country:US
Mailing Address - Phone:817-336-7191
Mailing Address - Fax:817-332-3172
Practice Address - Street 1:909 9TH AVE
Practice Address - Street 2:STE 300
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3903
Practice Address - Country:US
Practice Address - Phone:817-336-7191
Practice Address - Fax:817-332-3172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00J45AMedicare ID - Type Unspecified