Provider Demographics
NPI:1538140710
Name:PEDIATRIC SURGICAL ASSOCIATES OF FT. WORTH, P. A.
Entity Type:Organization
Organization Name:PEDIATRIC SURGICAL ASSOCIATES OF FT. WORTH, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-336-7881
Mailing Address - Street 1:901 7TH AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2722
Mailing Address - Country:US
Mailing Address - Phone:817-336-7881
Mailing Address - Fax:817-336-6821
Practice Address - Street 1:901 7TH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2722
Practice Address - Country:US
Practice Address - Phone:817-336-7881
Practice Address - Fax:817-336-6821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112632802Medicaid
TX112632804Medicaid
TX4641193OtherAETNA
TX4641193OtherAETNA