Provider Demographics
NPI:1578530226
Name:PHYSICIANS SURGICAL CENTER OF FT. WORTH LLP
Entity Type:Organization
Organization Name:PHYSICIANS SURGICAL CENTER OF FT. WORTH LLP
Other - Org Name:BAYLOR SCOTT & WHITE SURGICARE FORT WORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICARE AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:750 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2531
Mailing Address - Country:US
Mailing Address - Phone:817-529-2620
Mailing Address - Fax:817-877-1292
Practice Address - Street 1:750 12TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2531
Practice Address - Country:US
Practice Address - Phone:817-529-2620
Practice Address - Fax:817-877-1292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130267261QA1903X
TX008484261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174356901Medicaid
45C0001357Medicare Oscar/Certification
TXY17336Medicare UPIN
ASC344Medicare PIN