Basic Information
| Provider Information | |||||||||
| NPI: | 1497772081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROTHERTON | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8173324465 | ||||||||
| Practice Location | |||||||||
| Address1: | 1651 W ROSEDALE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761047437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173354316 | ||||||||
| FaxNumber: | 8173362504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | G3184 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 120310105 | 05 | TX | MEDICAID | 200045844 | 01 | TX | RAILROAD MEDICARE | OTHER |