Provider Demographics
NPI:1760635346
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:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-336-7191
Mailing Address - Street 1:909 NINTH AVENUE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3917
Mailing Address - Country:US
Mailing Address - Phone:817-336-7191
Mailing Address - Fax:817-332-3172
Practice Address - Street 1:9003 AIRPORT FREEWAY
Practice Address - Street 2:SUITE 300
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-9628
Practice Address - Country:US
Practice Address - Phone:817-514-5200
Practice Address - Fax:817-514-5210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2508208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB27834Medicare UPIN