Provider Demographics
NPI:1770503237
Name:FORT WORTH BRAIN & SPINE INSTITUTE, LLP
Entity Type:Organization
Organization Name:FORT WORTH BRAIN & SPINE INSTITUTE, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-878-5333
Mailing Address - Street 1:1900 MISTLETOE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4014
Mailing Address - Country:US
Mailing Address - Phone:817-878-5333
Mailing Address - Fax:817-878-5334
Practice Address - Street 1:1900 MISTLETOE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4014
Practice Address - Country:US
Practice Address - Phone:817-878-5333
Practice Address - Fax:817-878-5334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61650301207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158682801OtherTPI
TXDA1062OtherRAILROAD MEDICARE
TX158682801OtherTPI