Provider Demographics
NPI:1215704291
Name:CARDIOLOGY AND ELECTROPHYSIOLOGY CLINIC FORT WORTH PC
Entity type:Organization
Organization Name:CARDIOLOGY AND ELECTROPHYSIOLOGY CLINIC FORT WORTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TAMEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDLEBROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-239-9532
Mailing Address - Street 1:1001 12TH AVE STE 134
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 12TH AVE STE 134
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3927
Practice Address - Country:US
Practice Address - Phone:817-368-6480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty