Provider Demographics
NPI:1669628780
Name:FORT WORTH CLINIC SPECIALTY CARE, PLLC
Entity Type:Organization
Organization Name:FORT WORTH CLINIC SPECIALTY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:ZIMMERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-454-7965
Mailing Address - Street 1:212 CATTLEBARON PARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-9512
Mailing Address - Country:US
Mailing Address - Phone:817-454-7965
Mailing Address - Fax:
Practice Address - Street 1:212 CATTLEBARON PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76108-9512
Practice Address - Country:US
Practice Address - Phone:817-454-7965
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2508208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty