Provider Demographics
NPI:1720031958
Name:WEST SIDE ORTHOPAEDIC CLINIC
Entity Type:Organization
Organization Name:WEST SIDE ORTHOPAEDIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:GLICKFELD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-738-6668
Mailing Address - Street 1:1002 MONTGOMERY ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2662
Mailing Address - Country:US
Mailing Address - Phone:817-738-6668
Mailing Address - Fax:
Practice Address - Street 1:1002 MONTGOMERY ST
Practice Address - Street 2:SUITE 107
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2662
Practice Address - Country:US
Practice Address - Phone:817-738-6668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CJ8419OtherGROUP MEDICARE RR
TX0013HZOtherGROUP BCBS
TX00727RMedicare PIN