Basic Information
| Provider Information | |||||||||
| NPI: | 1235180035 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORT WORTH DIGESTIVE ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 470294 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761470294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178857888 | ||||||||
| FaxNumber: | 8178857811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 W ROSEDALE ST | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761047400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178857888 | ||||||||
| FaxNumber: | 8178857811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 10/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | AZIZ | ||||||||
| AuthorizedOfficialFirstName: | SHAHID | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8178857888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0074MU | 01 | TX | BCBS GROUP NUMBER | OTHER | DD9949 | 01 | MEDICARE RAILROAD | OTHER |