Provider Demographics
NPI:1679561641
Name:FORTH WORTH SURGICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:FORTH WORTH SURGICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PETTEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-370-9011
Mailing Address - Street 1:6100 HARRIS PKWY
Mailing Address - Street 2:#390
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4128
Mailing Address - Country:US
Mailing Address - Phone:817-370-9011
Mailing Address - Fax:817-346-0380
Practice Address - Street 1:6100 HARRIS PKWY
Practice Address - Street 2:#390
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4128
Practice Address - Country:US
Practice Address - Phone:817-370-9011
Practice Address - Fax:817-346-0380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8340208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
91159OtherAMERIGROUP
4254295OtherAETNA
4254295OtherAETNA
C20472Medicare UPIN