Basic Information
| Provider Information | |||||||||
| NPI: | 1801939244 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORT WORTH HEART, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 MISTLETOE BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173381300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 MISTLETOE BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173381300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 06/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | WOMACK | ||||||||
| AuthorizedOfficialFirstName: | MANDI | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATION MNGR | ||||||||
| AuthorizedOfficialTelephone: | 8173381300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | CP2325 | 01 | TX | MEDICARE RAILROAD GROUP | OTHER | 084424301 | 05 | TX | MEDICAID |