Provider Demographics
NPI:1447789896
Name:TEXAS SURGICAL ALLY
Entity Type:Organization
Organization Name:TEXAS SURGICAL ALLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURK
Authorized Official - Suffix:
Authorized Official - Credentials:LSA
Authorized Official - Phone:832-457-8868
Mailing Address - Street 1:6677 FRIENDSWAY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-7541
Mailing Address - Country:US
Mailing Address - Phone:832-457-8868
Mailing Address - Fax:
Practice Address - Street 1:6677 FRIENDSWAY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137
Practice Address - Country:US
Practice Address - Phone:832-457-8868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00468363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0089YLOtherBCBS